Prognostic factors after surgical resection for intrahepatic, hilar, and distal cholangiocarcinoma

Novel Ablation Therapy Using Endoscopic Irreversible Electroporation in the Bile Duct: A Pilot Animal Study

Background/Aims

Irreversible electroporation (IRE) is a relatively new ablation method. However, the application of IRE ablation in the treatment of biliary disease has not been attempted. A minimally invasive approach using endoscopic retrograde cholangiopancreatography (ERCP) can be a novel therapeutic modality for IRE ablation. In this study, we aimed to investigate the feasibility of endoscopic IRE for the biliary tract using an animal model.

Methods

A new catheter-type electrode was developed for endoscopic IRE ablation of the biliary tract. We performed ERCP and endoscopic IRE ablations in the normal common bile duct of Yorkshire pigs. The experimental setting of IRE was 500 V/cm (50 pulses, 100-µs length). The animals were sacrificed after 24 hr, and the ablated bile duct was examined.

Results

Well-demarcated focal color changes were observed on the mucosa of the common bile duct. The depth of change after IRE was confined to the mucosal and submucosal layers. Apoptotic changes in the bile duct were observed only around the IRE ablation area. Immunohistochemistry assay showed cell death in the bile duct along the electrode.

Conclusions

Endoscopic IRE ablation using ERCP was successfully performed in the common bile duct. It can be a potential option for the treatment of biliary tumors.

Survival analysis of patients with stage T2a and T2b perihilar cholangiocarcinoma treated with radical resection

BACKGROUND

Both the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (pCCA) had the same definition for T2a and T2b. But the value of this classification as prognostic factor remains unclear.

METHODS

178 patients with stage T2a or T2b who underwent curative intent resection for pCCA between Jan 2010 and Dec 2018 were enrolled. Relationships between survival and clinicopathological factors including patient demographics and tumor characteristics were evaluated using univariate and multivariate Cox regression analysis. The overall survival (OS) were calculated by Kaplan-Meier method.

RESULTS

There was no significant difference in OS between T2a and T2b groups, and the median OS duration were 37 and 31 months (P = 0.354). Both the 7th and 8th edition of the AJCC TNM staging demonstrated a poor prognostic predictive performance. High level of preoperative AST (≥85.0 IU/L) and CA19-9 (≥1000 U/mL), vascular resection and lower pathological differentiation of the tumor were the independent predictors for poor survival after resection.

CONCLUSION

The newly released 8th edition of AJCC staging system demonstrated a poor ability to discriminate the prognosis of patients with stage T2a and T2b pCCA after resection.

Retroduodenal resection of the extrahepatic common bile duct with in situ re-implantation of the main pancreatic duct: A report of two cases

Resection of the whole distal common bile duct (CBD) with in situ re-implantation of the main pancreatic duct can be a surgical option to avoid pancreaticoduodenectomy. in this study, we present two cases of cholangiocarcinomas with diffuse involvement of the extrahepatic CBD that was resected through a retroduodenal approach and re-implantation of the main pancreatic duct. The first case was a 70-year-old male patient with intraductal papillary neoplasm with invasive cholangiocarcinoma. He underwent retroduodenal resection of the whole CBD and in situ re-implantation of the main pancreatic duct. He was disease-free for 8 years, but tumor recurrence occurred at the hepaticojejunostomy site. This patient is currently undergoing chemoradiation therapy for treatment of recurrent lesions. The second case was a 71-year-old male patient with diffuse cholangiocarcinoma involving the whole extrahepatic CBD. He underwent medial sectionectomy, retroduodenal resection of the whole CBD and in situ re-implantation of the main pancreatic duct. He received postoperative chemoradiation therapy. He was disease-free for 3 years, but tumor recurrence occurred at the hepaticojejunostomy site. He passed away 4 years and 6 months after surgery. In conclusion, complete resection of the extrahepatic CBD through a retroduodenal approach with in situ re-implantation of the main pancreatic duct is feasible and less invasive than PD. Therefore, the proposed less-invasive approach can be an alternative procedure in selected patients requiring complete resection of the distal CBD.

Comparison of magnetic resonance imaging and 18-fludeoxyglucose positron emission tomography/computed tomography in the diagnostic accuracy of staging in patients with cholangiocarcinoma: A meta-analysis

BACKGROUND

Accurate clinical staging of patients with cholangiocarcinoma (CCA) has a significant impact on treatment decisions. In this study, we aimed to compare the diagnostic value of magnetic resonance imaging (MRI) and 18-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) for staging of CCA.

METHODS

We performed comprehensive systematic search in Web of Science (including MEDLINE) and Excerpta Medica Database for relevant diagnostic studies in accordance with the preferred reporting items for systematic reviews and meta-analysis statement. Based on data extracted from patient-based analysis, we calculated the pooled sensitivity and specificity with the 95% confidence intervals (CIs). In addition, the publication bias was assessed by Deek funnel plot of the asymmetry test. The potential heterogeneity was explored by threshold effect analysis and subgroup analyses.

RESULTS

Thirty-two studies with 1626 patients were included in present analysis. In T stage, the pooled sensitivity and specificity of MRI were 0.90 (95% CI 0.86-0.93), 0.84 (95% CI 0.73-0.91) respectively. The pooled sensitivity and specificity of F-FDG PET/CT were 0.91 (95% CI 0.83-0.95) and 0.85 (0.64-0.95) respectively. In N stage, the pooled sensitivity and specificity of MRI were 0.64 (95% CI 0.52-0.74) and 0.69 (95% CI 0.51-0.87) respectively. The pooled sensitivity and specificity of PET/CT were 0.52 (95% CI 0.37-0.66) and 0.92 (95% CI 0.79-0.97) respectively. In M stage, the pooled sensitivity and specificity of F-FDG PET/CT were 0.56 (95% CI, 0.42-0.69) and 0.95 (95% CI, 0.91-0.97) respectively. The Deek test revealed no significant publication bias. No threshold effect was identified. The subgroup analyses showed that pathological type (extrahepatic cholangiocarcinoma vs hilar cholangiocarcinoma/intrahepatic cholangiocarcinoma), country (Asia vs non-Asia) and type of MRI (1.5T vs. 3.0T) were potential causes for the heterogeneity of MRI studies and country (Asia vs non-Asia) was a potential source for F-FDG PET/CT studies.

CONCLUSION

The analysis suggested that both modalities provide reasonable diagnostic accuracy in T stage without significant differences between them. We recommend that both modalities be considered based on local availability and practice for the diagnosis of primary CCA tumors. In N stage, the diagnosis of lymph node metastasis (N) of CCA is still limited by MRI and F-FDG PET/CT, due to unsatisfactory diagnostic accuracy of both. Nevertheless, F-FDG PET/CT can be used to confirm lymph node metastasis while a negative result may not rule out metastasis. Furthermore, F-FDG PET/CT have a low sensitivity and a high specificity for detection of distant metastasis.

Proposal of the optimal numbers of examined and positive lymph nodes to the 8th edition of American Joint Committee on Cancer (AJCC) staging for 758 patients with distal cholangiocarcinoma

Introduction

The American Joint Committee on Cancer (AJCC) recommended retrieval of at least 12 lymph nodes and firstly classified N category by the number of positive lymph nodes (PLNs) for Distal Cholangiocarcinoma (DCC).

Objective

The end of this cohort study was to explore the optimal cut-off values of the number of examined lymph nodes (ELNs) and PLNs to better stratify patients by utilizing a population-based database.

Methods

A number of 758 patients with DCC from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled in the study and comparing by the survival analysis.

Results

Survival analysis found that patients with ELNs < 5 had a lower 3-year disease-specific survival rate than ELNs ≥ 5 in N0M0 cohort (35.3% vs. 53.0%, P = 0.001) and in M0 cohort (42.7% vs. 32.8%, P = 0.006); survival curves between patients with ELNs < 12 and ELNs ≥ 12 were overlapped in N0M0 cohort (P = 0.256) and in M0 cohort (P = 0.233). Among patients with ELNs ≥ 5, using the optimal cut-off value of the number of PLNs (0, 2) could accurately stratify patients, but the recommendation of the number of PLNs (0, 3) by the AJCC could not.

Conclusions

This study recommended examining at least 5 lymph nodes and defining PLNs = 1–2 as the N1 category and PLNs ≥ 3 as the N2 category, which may better stratify distal cholangiocarcinoma patients and improve the accuracy of the eighth edition AJCC staging.

[Long-term results of surgical treatment of intrahepatic cholangiocarcinoma]

OBJECTIVE

To evaluate the long-term outcomes of surgical treatment of intrahepatic cholangiocarcinoma depending tumor dimensions, vascular invasion, lymph node metastases, cellular differentiation and quality of resection.

MATERIAL AND METHODS

There were 46 patients with intrahepatic cholangiocellular cancer. Extended hemihepatectomy was made in 14 patients (30.4%), resection of two and three liver segments - in 17 cases (36.9%), standard hemihepatectomy - in 15 patients (32.6%). Liver resection was combined with extrahepatic bile duct resection in 5 (10.9%) patients. Liver resection was followed by biopsy of specimens. Dimension and number of tumors, differentiation grade, resection margin, liver capsule invasion, vascular invasion and regional lymph node metastases were analyzed. Forty-four (95.6%) patients were followed-up in long-term postoperative period. Statistical analysis was performed using Statistica 13.2 (Dell Inc., USA) and IBM SPSS Statistics v.25 (IBM Corp., USA) software package. Survival was analyzed using the Kaplan-Meier method. Overall 1-, 3- and 5-year survival rates with two-sided 95% confidence intervals (95% CI) were calculated using IBM SPSS Statistics v.25 software.

RESULTS

Median survival was 37 months, 1-year - 75.9% (60.9-90.9%), 3-year - 57.6% (35.5-79.6%), 5-year - 36% (8.2-63.7%). Median survival after R1 resection was 37 months, R2 resection - 12 months. Median survival was not achieved in R0 group. We found significant differences in overall survival depending on quality of resection. Tumor dimension over 5 cm, low-grade adenocarcinoma, microvascular invasion and lymph node metastases were associated with impaired postoperative survival. However, differences were not significant.

CONCLUSION

The main surgical strategy in patients with intrahepatic cholangiocarcinoma should be ensuring microscopically negative resection margin.

Galangin Inhibits Cholangiocarcinoma Cell Growth and Metastasis through Downregulation of MicroRNA-21 Expression

Galangin, a natural flavonoid product derived from the root of galangal, is emerging as a promising anticancer agent against multiple cancers. Yet, whether it also has antitumor effects on cholangiocarcinoma (CCA) and the underlying mechanism is still unknown. Herein, we demonstrate that galangin exhibits multiple antitumor effects on CCA cells including decreases cell viability; inhibits proliferation, migration, and invasion; and induces apoptosis. Moreover, those phenotypic changes are associated with downregulated microRNA-21 (miR-21) expression. To support, overexpression of miR-21 blocks galangin-mediated antisurvival and metastasis effects on CCA cells. Mechanically, galangin increases the expression of phosphatase and tensin homolog (PTEN), a direct target of miR-21, resulting in decreased phosphorylation of AKT, a protein kinase which plays a critical role in controlling survival and apoptosis. In contrast, overexpression of miR-21 abrogates galangin-regulated PTEN expression and AKT phosphorylation. Taken together, these findings indicate that galangin inhibits CCA cell proliferation and metastasis and induces cell apoptosis through a miR-21-dependent manner, and galangin may provide a novel potential therapeutic adjuvant to treat CCA.

Multimodality treatment in unresectable cholangiocarcinoma

Purpose

Cholangiocarcinomas (CCs) are rare and highly malignant cancers. Although there are different treatment protocols for treatment of cholangiocarcinoma, we aimed to investigate a survival rate of patients with unresectable extrahepatic CCs (ECCs) receiving multimodality therapeutic protocol (MTP) (biliary drainage + external beam radiotherapy [EBRT] + brachytherapy and systemic chemotherapy). Similarly, we aimed to identify a relationship between survival time and associated factors in treatment outcome.

Material and methods

This retrospective study was performed on patients with ECC, who were referred to our university hospital between 2012 and 2015, and their imaging were diagnosed as unresectable. Patients underwent MTP including internal-external drainage catheter (F10-12) with insertion under fluoroscopy guidance, EBRT with 25-28 fractions and concurrent chemotherapy using capecitabine (Xeloda) 825 mg/m² at the days of radiotherapy, followed by brachytherapy (BT) with iridium-192 (¹⁹²Ir) or cobalt-60 (⁶⁰Co) sources for 21 Gy in 3 consecutive days. Demographic variables, complications, laboratory tests, imaging findings, and survival time (OS - overall survival after diagnosis; CS - survival after catheter placement) were recorded.

Results

A total of 38 patients, with mean SD age = 58.08 (9.80) years, male = 22 (57.9%), were evaluated. According to Bismuth-Corlette classification, 15 (39.5%) were in stage IIIA, 5 (13.2%) were in stage IIIB, 10 (26.3%) were in stage IV, and 8 (21.2%) were undefined. Of those, 21 (55.3%), 15 (39.5%), and 17 (44.7%) were involved with liver parenchyma, great vessels, and regional lymph nodes, respectively. Mean SD of OS was 15.11 (8.10) months (median = 15; 95% CI: 13.25-16.69), and CS was 2-29 months (mean SD = 11.71 (7.29); median = 10; 95% CI: 10.05-13.37). Further analysis revealed a considerable decrease in OS and CS in those with an involvement of liver parenchyma, great vessels, regional lymph nodes, and Bismuth type IV.

Conclusions

Multimodality therapeutic approach in patients with inoperable ECCs could definitely improve their survival time and decrease complications. Survival time is significantly depending on tumor staging, gender, and involvement of liver parenchyma, great vessels, and regional lymph nodes.

Proposed Modification of Staging for Distal Cholangiocarcinoma Based on the Lymph Node Ratio Using Korean Multicenter Database

The 8th American Joint Committee on Cancer (AJCC) staging system for distal cholangiocarcinoma (DCC) included a positive lymph node count (PLNC), but a comparison of the prognostic predictive power of PLNC and lymph node ratio (LNR) is still under debate. This study aimed to compare various staging models made by combining the abovementioned factors, identify the model with the best predictive power, and propose a modified staging system. We retrospectively reviewed 251 patients who underwent surgery for DCC at four centers. To determine the superiority of various staging models for predicting overall OSR, Akaike information criterion (AIC), Bayesian information criterion (BIC), AIC correction (AICc), and Harrell’s C-statistic were calculated. In multivariate analysis, age (p = 0.003), total lymph node count (p = 0.033), and revised T(LNR)M staging (p < 0.001) were identified as independent factors for overall survival rate. The predictive performance of revised T (LNR) M staging (AIC: 1288.925, BIC: 1303.377, AICc: 1291.52, and Harrell’s C statics: 0.667) was superior to other staging system. A modified staging system consisting of revised T category and LNR predicted better overall survival of DCC than AJCC 7th and AJCC 8th editions. In the future, external validation of the proposed new system using a larger cohort will be required.

Neoadjuvant chemotherapy with gemcitabine plus cisplatin followed by radical liver resection versus immediate radical liver resection alone with or without adjuvant chemotherapy in incidentally detected gallbladder carcinoma after simple cholecystectomy or in front of radical resection of BTC (ICC/ECC) - a phase III study of the German registry of incidental gallbladder carcinoma platform (GR)- the AIO/ CALGP/ ACO- GAIN-trial

BACKGROUND

Currently, complete surgical resection represents the only potentially curative treatment option for Biliary Tract Cancer (BTC) including Gallbladder Cancer (GBC). Even after curative resection, 5-year OS is only 20-40%. Gallbladder carcinoma is relatively rare, but still the fifth most common neoplasm of the digestive tract and even the most frequent cancer of the biliary system. Gallbladder carcinoma is suspected preoperatively in only 30% of all pts., while the majority of cases are discovered incidentally by the pathologist after cholecystectomy for a benign indication. For improving curative rates in BTC and GBC, early systemic therapy combined with radical resection seems to be a promising approach. The earliest moment to apply chemotherapy would be in front of radical surgery. The encouraging results of neoadjuvant/perioperative concepts in other malignancies provide an additional rationale to use this treatment in the early phase of GBC management and even ICC/ECC. Especially because data regarding pure adjuvant chemotherapy in BTC's are conflicting.

METHODS

This is a multicenter, randomized, controlled, open-label phase III study including pts. with incidentally discovered GBCs after simple cholecystectomy in front of radical liver resection and pts. with resectable/ borderline resectable cholangiocarcinomas (ICC/ ECC) scheduled to receive perioperative chemotherapy (Gemcitabine + Cisplatin 3 cycles pre- and post-surgery) or surgery alone followed by a therapy of investigator's choice. Primary endpoint is OS; secondary endpoints are PFS, R0-resection rate, toxicity, perioperative morbidity, mortality and QoL. A total of N = 333 patients with GBC or BTC will be included. Recruitment has started in August 2019.

DISCUSSION

The current proposed phase III GAIN study investigates whether induction chemotherapy followed by radical resection in ICC/ECC and re-resection in IGBC (and - if possible - postoperative chemotherapy) prolongs overall survival compared to radical surgery alone for incidental gallbladder carcinoma and primary resectable or borderline resectable cholangiocarcinoma. Utilizing a neoadjuvant approach including a second radical surgery will help to raise awareness for the necessity of radical surgery, especially second radical completion surgery in IGBC and improve the adherence to the guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03673072 from 17.09.2018. EudraCT number: 2017-004444-38 from 02.11.2017.

Comparison of the effects of adjuvant concurrent chemoradiotherapy and chemotherapy for resected biliary tract cancer

Background

Biliary tract cancers (BTC) have a poor prognosis even after curative resection because of frequent local and distant recurrences. Therefore, the importance of adjuvant therapy in BTC has been advocated to improve outcomes. However, the choice of adjuvant therapy is still controversial. The aim of this study was to compare the effects of adjuvant concurrent chemoradiotherapy (CCRT) and chemotherapy on resected BTC.

Methods

We analyzed 92 patients who had curatively resected BTC and had received adjuvant CCRT or chemotherapy from January 2000 to December 2017 at Keimyung University Dongsan Medical Center.

Results

Of the patients, 46 received adjuvant CCRT and 46 received adjuvant chemotherapy. The median recurrence-free survival (RFS) for the adjuvant CCRT and chemotherapy groups were 13.8 and 11.2 months (p = 0.014), respectively. The median overall survival (OS) for the adjuvant CCRT and chemotherapy groups were 30.1 and 26.0 months (p = 0.222), respectively. Adjuvant CCRT had significantly better RFS and numerically higher OS than did chemotherapy. For subgroups with no lymph node (LN) involvement (RFS p = 0.006, OS p = 0.420) or negative resection margins (RFS p = 0.042, OS p = 0.098), adjuvant CCRT led to significantly longer RFS and numerically higher OS than did chemotherapy. For multivariate analysis, the pattern of adjuvant treatment (chemotherapy vs. CCRT, p = 0.004, HR 2.351), histologic grade (poor vs. well, p = 0.023, HR 4.793), and LN involvement (p = 0.028, HR 1.912) were the significant prognostic factors for RFS.

Conclusions

Our study demonstrated the superiority of adjuvant CCRT over chemotherapy for improving RFS in curatively resected BTC.

Robotic radical surgery for hilar cholangiocarcinoma: A single-centre case series

BACKGROUND

Radical resection for hilar cholangiocarcinoma is considered one of the most complicated abdominal operations. We report our initial experience with robotic radical resection for hilar cholangiocarcinoma.

METHODS

Between March 2017 and February 2019, the perioperative outcomes of 48 patients were analysed. In addition, there were two techniques for hepaticojejunostomy in the robotic approach. Comparison of the conventional and novel methods for hepaticojejunostomy was also performed to assess the efficacy of the technique.

RESULTS

The operative duration and intraoperative blood loss volume was 276 minutes and 150 mL, respectively. The overall morbidity was 58.3% and the major morbidity was 10.4%. The overall mortality was 0%. No significant differences in the perioperative outcomes of hepaticojejunostomy were found between the 2 groups.

CONCLUSION

Robotic resection is a potential alternative to open surgery for appropriately selected patients with hilar cholangiocarcinoma. Further studies are required to detect the long-term outcomes of this procedure.

Regional lymphadenectomy vs. extended lymphadenectomy for hilar cholangiocarcinoma (Relay-HC trial): study protocol for a prospective, multicenter, randomized controlled trial

Background

The prognostic benefits and safety of extended lymphadenectomy for hilar cholangiocarcinoma remain uncertain. The available evidence is still insufficient concerning its retrospective aspect. The aim of this study is to explore the clinical effect and safety of extended lymphadenectomy compared to regional lymphadenectomy in patients with hilar cholangiocarcinoma.

Methods

The Relay-HC trial is a prospective, multicenter, and randomized controlled trial. Seven hundred and thirty-four eligible patients with resectable perihilar cholangiocarcinoma across 15 tertiary hospitals in China will be randomly assigned (1:1) to receive either regional lymphadenectomy or extended lymphadenectomy. The primary objective is to determine the overall survival after the two approaches. Secondary objectives of the study include the evaluation of perioperative mortality, postoperative complication, and disease-free survival. This study has been approved by the ethics committee of each participating hospital.

Discussion

The Relay-HC trial is designed to investigate the prognostic benefits and safety of expanded lymphadenectomy for hilar cholangiocarcinoma. Currently, it has never been investigated in a prospective randomized controlled clinical trial.

Trial registration

Chinese Clinical Trial Registry (ChiCTR), ChiCTR1800015688. Registered on 15 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3605-z) contains supplementary material, which is available to authorized users.

Surgery for cholangiocarcinoma

Surgical resection is the only potentially curative treatment for patients with cholangiocarcinoma. For both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA), 5-year overall survival of about 30% has been reported in large series. This review addresses several challenges in surgical management of cholangiocarcinoma. The first challenge is diagnosis: a biopsy is typically avoided because of the risk of seeding metastases and the low yield of a brush of the bile duct. However, about 15% of patients with suspected pCCA are found to have a benign diagnosis after resection. The second challenge is staging; even with the best preoperative imaging, a substantial percentage of patients has occult metastatic disease detected at staging laparoscopy or early recurrence after resection. The third challenge is an adequate volume and function of the future liver remnant, which may require preoperative biliary drainage and portal vein embolization. The fourth challenge is a complete resection: a positive bile duct margin is not uncommon because the microscopic biliary extent of disease may be more extensive than perceived on imaging. The fifth challenge is the high post-operative mortality that has decreased in very high volume Asian centres, but remains about 10% in many Western referral centres. The sixth challenge is that even after a complete resection most patients develop recurrent disease. Recent randomized controlled trials found conflicting results regarding the benefit of adjuvant chemotherapy. The final challenge is to determine which patients with cholangiocarcinoma should undergo liver transplantation rather than resection.

Prognostic comparison of the longitudinal margin status in distal bile duct cancer: R0 on first bile duct resection versus R0 after additional resection

BACKGROUND

This study investigated survival differences following intra-operative frozen-section examination of bile duct resection margins and final longitudinal margin status (LMS) in distal bile duct cancer (BDC).

METHODS

One hundred and ninety-three patients underwent Whipple's operation for curative resection of distal BDC from 2008 to 2016. Patients were sorted into two and three groups according to LMS of the frozen-sections and the final pathological specimen results: R0 on first bile duct resection (primary R0), R0 after additional resection (secondary R0), and no evidence of residual carcinoma (FR0), carcinoma in situ or high-grade dysplasia (FR1-CIS/HGD), or invasive carcinoma (FR1-INV). Survival and prognostic factors according to LMS were analyzed.

RESULTS

The final R0 ratio increased from 82.3% to 90.1% through additional resection. The 5-year overall survival (OS) of primary and secondary R0 were 60.8%, 46.1% (P = 0.969). And disease-free survival of primary and secondary R0 were 54.6%, 54.9% (P = 0.903). The 5-year OS after FR0, FR1-CIS/HGD, FR1-INV were 59.3%, 59.5%, 14.3% (P = 0.842). LMS of the bile duct was an independent prognostic factor by multivariable analyses.

CONCLUSIONS

If R0 of final LMS was achieved, it would help to improve survival regardless of R0 through additional resection. And, it should be avoided remaining invasive cancer at the longitudinal margin whenever possible.

The effect of adjuvant chemotherapy in resectable cholangiocarcinoma: A meta-analysis and systematic review

BACKGROUND

The benefit of adjuvant chemotherapy for resectable cholangiocarcinoma remains unclear due to the lack of randomized control studies. This study aimed to investigate the possible benefit of postoperative adjuvant chemotherapy for resectable cholangiocarcinoma.

DATA SOURCES

Relevant research articles published before 1st March 2018 in PubMed, Embase and the Cochrane library databases were retrieved. Published data were extracted and analyzed by RevMan 5.3, and the results were presented as hazard ratios (HRs) [95% confidence intervals (CI)] and forest plots.

RESULTS

One prospective and eighteen retrospective studies were included, with a total number of 11,458 patients, 4696 of whom received postoperative chemotherapy. There was a significant improvement of the overall survival (OS) for patients who underwent operation + adjuvant chemotherapy compared to those who underwent operation alone (HR = 0.61; P < 0.001). Subgroup analyses show that the postoperative chemotherapy group compared with operation alone group are indicated as follows: hilar cholangiocarcinoma group (HR = 0.60; P < 0.001), intrahepatic cholangiocarcinoma group (HR = 0.60; P < 0.001), R1 resection group (HR = 0.71; P = 0.04), LN-positive diagnosis group (HR = 0.58; P < 0.001), gemcitabine-based chemotherapy group (HR = 0.42; P < 0.001), distal cholangiocarcinoma group (HR = 0.48; P = 0.17), R0 resection group (HR = 0.69; P = 0.43), and 5-flurouracil-based chemotherapy group (HR = 0.90; P = 0.66), respectively.

CONCLUSIONS

Postoperative adjuvant chemotherapy can improve the OS in intrahepatic and hilar cholangiocarcinoma patients. However, distal cholangiocarcinoma patients gain no benefit from postoperative adjuvant chemotherapy. Prospective randomized trials are warranted in order to define the standard chemotherapy regimen.

Second primary malignancy in patients with cholangiocarcinoma: a population-based study

Background

A population-based estimate of risk of second primary malignancy (SPM) in patients with cholangiocarcinoma (CCA) is still lacking.

Objectives

To investigate the overall and site-specific risk of SPM in patients with CCA. To identify risk factors of SPM and further evaluate the impact of SPM on overall survival (OS) and disease specific survival (DSS) in patients with CCA.

Methods

Patients with histologically diagnosed CCA between 1973 and 2015 were identified from the Surveillance, Epidemiology and End Results database. Standardized incidence ratio (SIR) was calculated. Risk factors for SPM and CCA survival were evaluated by logistic, Cox, and nomogram methods.

Results

We found that the overall risk of SPM in patients with CCA was significantly higher than that in the general population (SIR =1.27, 95% CI =1.03–1.55, P<0.05). The risk of SPM was significantly increased at specific sites, including transverse colon, intrahepatic bile duct, other biliary, and thyroid. A significant increase in overall risk was characterized in the subgroups of patients aged ≤29, patients aged 30–59 years, females, whites, and patients with latency ≤11 months (63.41, 2.45, 1.4, 1.3, and 2.6-fold, respectively). In patients with CCA, not having undergone surgery for the first primary malignancy (vs having undergone surgery for the first primary malignancy; HR =0.269; 95% CI =0.211–0.342; P<0.001) was associated with significantly decreased risk of SPM. Patients with SPM had better OS and DSS than those without SPM (Log rank P<0.001). Absence of SPM was an independent risk factor for poorer OS and DSS.

Conclusion

Although the risk of SPM in patients with CCA was significantly increased, the presence of SPM did not shorten OS and DSS of patients with CCA, possibly due to the relatively poorer survival of patients with CCA.

Comparison of long-term efficacy between endoscopic and percutaneous biliary drainage for resectable extrahepatic cholangiocarcinoma with biliary obstruction: A systematic review and meta-analysis

BACKGROUND/AIM

For resectable extrahepatic cholangiocarcinoma with biliary obstruction, it remains a controversy whether to choose percutaneous transhepatic biliary drainage (PTBD) or endoscopic biliary drainage (EBD). A systematic review was conducted to compare the long-term efficacy between the two techniques.

MATERIALS AND METHODS

Eligible studies were searched from January 1990 to May 2018, comparing the long-term efficacy between EBD and PTBD for extrahepatic cholangiocarcinoma. Primary end point was overall survival (OS) rate, and secondary end points included postoperative severe complications and seeding metastasis. Effect size on outcomes was calculated using a fixed- or random-effect model, accompanied with hazard ratio (HR) and 95% confidence interval (CI).

RESULT

Six studies were included in this meta-analysis. Meta-analysis showed that EBD was superior to PTBD in OS (HR = 0.70, 95% CI 0.59-0.84,P= 0.0002). But subgroup results showed that the superiority disappeared in distal cholangiocarcinoma (HR = 0.76, 95% CI 0.56-1.01,P= 0.06). Other prognostic factors such as intraoperative blood transfusion, lymphatic metastasis and seeding metastasis, were inconsistent between groups. In addition, regional disparity was obviously apparent between Japanese and non-Japanese studies.

CONCLUSION

The conclusion that EBD was superior to PTBD in OS for resectable extrahepatic cholangiocarcinoma with biliary obstruction is less convincing, and more trials need to be conducted in future.

[Cholangiocellular cancer: the state of the problem and ways to improve the results of surgical treatment]

AIM

To improve the outcomes in patients with resectable biliary cancer.

MATERIAL AND METHODS

There were 263 procedures for cholangiocellular carcinoma (CCC) for the period 1998—2017. Adjuvant chemotherapy was performed in 102 (38.8%) patients. Extensiveliver resections (78.9%) prevailed for intrahepatic cholangiocellular carcinoma (n=128), 6 (4.7%) patients required vascular resection. Seventy-seven pancreatoduodenectomies were performed for common bile duct cancer, portal vein resection was done in 8 (10.4%) patients. In case of Klatskin tumor (n=58) liver resection combined with bile duct resection (n=52) prevailed. Portal vein resection was done in 16 (27.6%) patients.

RESULTS

Postoperative morbidity in patients with intrahepatic CCC was revealed in 68 (53.1%) cases, mortality — in 5 (3.9%) cases. Among patients with Klatskin tumor morbidity was revealed in 51 (87.9%) cases, mortality — in 6 (10.3%) cases. In patients with common bile duct cancer morbidity was revealed in 53 (68.8%) cases, mortality — in 4 (5.2%) cases. In whole cohort median overall survival was 30 months. R0-resection was associated with better long-term results (median 37 months) compared with R1—R2 resection (20 months; p=0.01). Lymph node involvement is associated with significantly worse prognosis (p=0.016), however 5-year survival is observed (25.6%). Adjuvant chemotherapy in R0-resection significantly improved long-term results: median was 46 months (vs. 30 in group without chemotherapy; p=0.02). In intrahepatic CCC patients multiple lesions or mechanical jaundice did not aggravate long-term results.

CONCLUSION

R0-resection including lymphadenectomy, resection of adjacent organs and vessels is advisable for CCC. Isolated bile duct resection should be used as an exception. Adjuvant therapy improved long-term results. Multiple lymph node lesion or bile duct infiltration are not contraindications to surgery in intrahepatic CCC patients.

Nonanatomic resection is not inferior to anatomic resection for primary intrahepatic cholangiocarcinoma: A propensity score analysis

Whether anatomic resection (AR) achieves better outcomes than nonanatomic resection (NAR) in patients with primary intrahepatic cholangiocarcinoma (ICC) is unclear. Data were retrieved for all consecutive patients who underwent liver resection for primary ICC from January 2007 to July 2017. The prognoses of the patients without direct invasion to contiguous organs or extrahepatic metastasis who underwent AR or NAR were compared. 85 patients underwent AR, and 65 patients underwent NAR. operation time were slightly decreased in the NAR group. The risk of Clavien-Dindo classification (CDC) IV in the AR group was significant higher than that in the NAR group. Cox regression analysis showed lymph node metastasis and adjuvant therapy were significant prognostic factors for overall survival (OS) and disease-free survival (DFS), respectively. After 1:1 propensity score matching (PSM), 29 pairs of patients were compared. The survival curves showed the NAR group had slightly improved DFS and OS than the AR group before and after matching. Thus, we conclude NAR was not inferior to AR in improving the survival outcomes for patients with primary solitary ICC lesions without direct invasion to contiguous organs or extrahepatic metastasis. Furthermore, patients may benefit from NAR.

Prognostic Significance of the Lymph Node Ratio in Surgical Patients With Distal Cholangiocarcinoma

BACKGROUND

The aim of this study was to compare the prognostic impact of the lymph node ratio (LNR) versus positive lymph node count (PLNC) in patients who had undergone resection for distal cholangiocarcinoma.

METHODS

We identified 448 patients with resected distal cholangiocarcinoma from the Surveillance, Epidemiology, and End Results database. The X-Tile program was used to calculate the cutoff values for the LNR and PLNC that discriminate survival. The overall survival and cancer-specific survival rates were calculated. Relationships between clinicopathological factors and patient survival were assessed using univariate and multivariate analyses.

RESULTS

The optimal cutoff values for the LNR and PLNC were 0.45 and 3, respectively. Univariate analysis revealed that tumor size, the American Joint Committee on Cancer stage, T stage, the LNR and PLNC were significantly associated with prognosis (P < 0.05). Multivariate analysis demonstrated that the LNR, T stage, and tumor size were independent prognostic factors for cancer-specific and overall survival, whereas PLNC was not. In the subgroup of patients with positive lymph nodes, patients with an LNR of greater than 0.45 had significantly worse cancer-specific survival (hazard ratio, 2.418; 95% confidence interval, 1.588 to 3.682; P < 0.001) and overall survival (hazard ratio, 2.149; 95% CI, 1.421 to 3.249; P < 0.001) than those with an LNR of 0.45 or less.

CONCLUSIONS

The LNR was a better predictor of long-term prognosis than PLNC in patients with distal cholangiocarcinoma.

Improved Survival in Surgically Resected Distal Cholangiocarcinoma Treated with Adjuvant Therapy: a Propensity Score Matched Analysis

BACKGROUND

Data on the efficacy of adjuvant therapy (AT) in distal cholangiocarcinoma (dCCA) is limited. This study aimed to determine the role of AT in resected dCCA and identify subgroups that benefit from AT.

METHODS

We conducted a retrospective review of surgically resected dCCA in the NCDB from 2004 to 2013. Patients who received AT or observation (OB) were matched by propensity score. Log-rank test was used to compare OS.

RESULTS

Of 1782 patients with resected dCCA, 840 (47%) were in the OB group and 942 (53%) in the AT group. AT was younger (64.0 vs. 68.7 years, p < 0.001), had less comorbidities (Charlson Deyo score 0) (74.6 vs. 68.0%, p < 0.001), and more likely to have private insurance (p < 0.001). AT was more likely to present with T3/T4 stage (72 vs. 57%, p < 0.001), N1/N2 disease (58 vs. 37%, p < 0.001), and positive surgical margins (26 vs. 16%, p < 0.001). After 1:1 propensity score matching, 500 OB and 500 AT patients were compared. AT was associated with better OS (HR 0.79; 95% CI 0.67-0.93). Median OS was 31 and 25 months for the AT and OB (p = 0.006). The 1-, 3-, and 5-year survival rates were 87, 46, and 31% for AT; 79, 39, and 24% for OB. Subgroup analysis revealed an associated survival advantage for AT in T3/T4 tumors (HR = 0.72; 95% CI 0.59-0.89), node positive disease (HR 0.70; 95% CI 0.56-0.87), and positive margins (HR 0.58; 95% CI 0.42-0.81).

CONCLUSION

AT is associated with improved OS in resected dCCA, especially in T3/T4 tumors, node positive disease, and positive margins.

Pancreaticoduodenectomy for periampullary cancer: does the tumour entity influence perioperative morbidity and long-term outcome?

BACKGROUND

Malignant tumours of the periampullary region include ductal adenocarcinoma of the pancreas (Pan-Ca), distal bile duct cancer (DBDC) and adenocarcinoma of the ampulla (Amp-Ca). The present retrospective clinical study was designed to evaluate the influence of tumour entity on postoperative complications and identify risk factors predicting survival and morbidity.

METHODS

We retrospectively analysed data from all patients who underwent pancreatic resection for periampullary cancer with curative intent (R0 or R1). Demographic data, risk factors, perioperative complications and survival rates for the different subtypes were assessed.

RESULTS

A total of 225 patients with periampullary cancer were identified: 124 (55.1%) had Pan-Ca, 55 (24.4%) had DBDC and 46 had (20.4%) Amp-Ca. Sixty-nine patients (30.7%) had major complications (grade IIIb-V). Patients with DBDC had significantly more grade C pancreatic fistulas. Univariate analysis revealed male gender, BMI >30, R1-status, and low-grade tumour differentiation as risk factors for major complications. Overall in-hospital-mortality was 6.7%.

CONCLUSIONS

Further research will be needed to implement more individualized therapy.

Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved?

Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.

Decreased argininosuccinate synthetase expression in Thai patients with cholangiocarcinoma and the effects of ADI-PEG20 treatment in CCA cell lines

Cholangiocarcinoma (CCA) is a severe cancer with poor prognosis. The aim of the present study was to explore the expression of argininosuccinate synthetase (ASS), as well as the possibility of using pegylated arginine deiminase (ADI-PEG20) for the treatment of CCA. ASS expression was determined in CCA specimens from 40 patients in Thailand. Immunohistochemical detection of ASS and determination of the proliferative index, Ki-67, were carried out in paraffin-embedded sections of these specimens, as well as in two CCA cell lines, HuCCA and RmCCA-1, derived from CCA samples from patients in Thailand. In total, ~45% of the CCA specimens had low ASS expression, and the level of expression was significantly negatively associated with cell differentiation (P<0.05) and Ki-67 expression (P<0.05). The level of ASS expression in tumor cells was significantly lower than that in non-tumor cells (1.3-fold, P<0.05). The HuCCA cell line had significantly lower levels (P<0.05) of ASS expression at the mRNA and protein levels relative to those of normal human immortalized fibroblast cells (BJ-1). By contrast, the RmCCA-1 cell line showed no significant difference. In addition, the effects of ADI-PEG20 on growth inhibition, apoptosis and cell cycle arrest were determined in HuCCA and RmCCA-1 cells. ADI-PEG20 treatment reduced cell viability and cell proliferation in the two CCA cell lines, though it had no effect in immortalized BJ-1 cells. Furthermore, ADI-PEG20 treatment significantly increased G0/G1 cell cycle arrest in HuCCA, though not in RmCCA-1 cells. ASS silencing in the RmCCA-1 cell line significantly enhanced its sensitivity to ADI-PEG20 treatment. Results from the in vitro study demonstrated that ADI-PEG20 has antitumor activity against CCA with low ASS expression.

Prognostic factors for operable biliary tract cancer: serum levels of lactate dehydrogenase, a strong association with survival

Background

Biliary tract cancers (BTCs) are uncommon but fatal, with a low 5-year survival rate after surgical resection. This study was designed to investigate the prognostic factors for operable BTC.

Methods

Baseline demographics at diagnosis were retrospectively evaluated in 341 BTC patients undergoing radical surgery at The First Affiliated Hospital of Nanjing Medical University from January 2011 to December 2015. The association between prognostic factors and overall survival (OS) was determined by multivariate analysis using the Cox proportional hazards regression model.

Results

Our study showed that 341 patients were included in the analysis, of which 166 (48.7%) were males and 175 (51.3%) were females. Older age, depth of tumor invasion, positive surgical margin, lower hemoglobin, and higher lactic dehydrogenase (LDH) were associated with significantly worse OS using multivariate analysis. In the entire cohort, the estimate of median OS in patients with LDH <271 U/L was 36.291 months (95% CI; 30.989–41.594 months), and 30.736 months (95% CI; 19.154–42.318 months) in patients with LDH ≥271 U/L (adjusted HR-1.505, 95% CI; 1.009–2.245, P = 0.045). Moreover, it was investigated whether serum LDH retained its significance as a prognostic marker in BTC subgroups separately. The results showed that LDH was prognostic in patients with distal bile duct (DBD) carcinoma undergoing radical surgery (HR-2.452, 95% CI; 1.167–5.152, P = 0.018). However, there were no statistical differences between LDH and OS in multivariate analysis in the other three individual subgroups except for DBD carcinoma. This may be due to the limited number of patients in the study, indicating that a greater number of patients may be required for statistical significance.

Conclusion

Older age, depth of tumor invasion, positive surgical margin status, lower hemoglobin levels, and elevated serum LDH level are associated with poor survival in operable BTC patients. Serum LDH level is a cost-effective prognostic biomarker in patients with operable BTC and especially DBD carcinoma.

Prognostic value of lymph nodes count on survival of patients with distal cholangiocarcinomas

AIM

To evaluate the prognostic value of the number of retrieved lymph nodes (LNs) and other prognostic factors for patients with distal cholangiocarcinomas, and to determine the optimal retrieved LNs cut-off number.

METHODS

The Surveillance, Epidemiology and End Results database was used to screen for patients with distal cholangiocarcinoma. Patients with different numbers of retrieved LNs were divided into three groups by the X-tile program. X-tile from Yale University is a useful tool for outcome-based cut-point optimization. The Kaplan-Meier method and Cox regression analysis were utilized for survival analysis.

RESULTS

A total of 449 patients with distal cholangiocarcinoma met the inclusion criteria. The Kaplan-Meier survival analysis for all patients and for N1 patients revealed no significant differences among patients with different retrieved LN counts in terms of overall and cancer-specific survival. In patients with node-negative distal cholangiocarcinoma, patients with four to nine retrieved LNs had a significantly better overall (P = 0.026) and cancer-specific survival (P = 0.039) than others. In the subsequent multivariate analysis, the number of retrieved LNs was evaluated to be independently associated with survival. Additionally, patients with four to nine retrieved LNs had a significantly lower overall mortality risk [hazard ratio (HR) = 0.39; 95% confidence interval (CI): 0.20-0.74] and cancer cause-specific mortality risk (HR = 0.32; 95%CI: 0.15-0.66) than other patients. Additionally, stratified survival analyses showed persistently better overall and cancer-specific survival when retrieving four to nine LNs in patients with any T stage of tumor, a tumor between 20 and 50 mm in diameter, or a poorly differentiated or undifferentiated tumor, and in patients who were ≤ 70-years-old.

CONCLUSION

The number of retrieved LNs was an important independent prognostic factor for patients with node-negative distal cholangiocarcinoma. Additionally, patients with four to nine retrieved LNs had better overall and cancer-specific survival rates than others, but the reason and mechanism were unclear. This conclusion should be validated in future studies.

Adjuvant therapy is associated with improved survival after curative resection for hilar cholangiocarcinoma: A multi-institution analysis from the U.S. extrahepatic biliary malignancy consortium

BACKGROUND

Curative-intent treatment for localized hilar cholangiocarcinoma (HC) requires surgical resection. However, the effect of adjuvant therapy (AT) on survival is unclear. We analyzed the impact of AT on overall (OS) and recurrence free survival (RFS) in patients undergoing curative resection.

METHODS

We reviewed patients with resected HC between 2000 and 2015 from the ten institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium. We analyzed the impact of AT on RFS and OS. The probability of RFS and OS were calculated in the method of Kaplan and Meier and analyzed using multivariate Cox regression analysis.

RESULTS

A total of 249 patients underwent curative resection for HC. Patients who received AT and those who did not had similar demographic and preoperative features. In a multivariate Cox regression analysis, AT conferred a significant protective effect on OS (HR 0.58, P = 0.013), and this was maintained in a propensity matched analysis (HR 0.66, P = 0.033). The protective effect of AT remained significant when node negative patients were excluded (HR 0.28, P = 0.001), while it disappeared (HR 0.76, P = 0.260) when node positive patients were excluded.

CONCLUSIONS

AT should be strongly considered after curative-intent resection for HC, particularly in patients with node positive disease.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma

INTRODUCTION

The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1).

PATIENTS AND METHODS

All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC.

RESULTS

The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups.

CONCLUSION

Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

Adjuvant chemotherapy for resected biliary tract cancers: a systematic review and meta-analysis

INTRODUCTION

The use of adjuvant treatment (AT) in resected biliary tract cancers (BTC) is still controversial. No efficacy comparison has been performed between chemotherapy (CT) and chemoradiotherapy (CTRT). A systematic review of the available evidence regarding adjuvant chemotherapy (AC) in resected BTC was performed.

METHODS

PubMed, EMBASE, Web of Science, SCOPUS and The Cochrane Library databases were searched for relevant articles published. Only studies including at least 50 patients affected by tumors of gallbladder, intrahepatic, perihilar, and distal bile ducts were considered. Data were pooled using a random-effects model. The primary endpoint of the study was overall survival (OS).

RESULTS

Thirty studies were analyzed with a total of 22,499 patients, 3967 of whom received AC. Eleven cohorts included Western patients and 19 were Asiatic. Surgeries were classified as R0 with negative margins, R1 with positive microscopic and R2 with positive macroscopic margins. Weighted mean OS difference among experimental (AC) and control arm was 4.3 months (95% CI 0.88-7.79, P = 0.014). AC reduced the risk of death by 41% (Hazard ratio [HR] = 0.59, 95% CI 0.49-0.71; P < 0.001).

CONCLUSIONS

AC administration gives an OS benefit in resected BTC. The results of prospective randomized studies are awaited in order to define the standard AT in BTC.

Cholangiocarcinoma: Current Knowledge and New Developments

Cholangiocarcinoma (CCA) is the second most common primary malignancy. Although it is more common in Asia, its incidence in Europe and North America has significantly increased in recent decades. The prognosis of CCA is dismal. Surgery is the only potentially curative treatment, but the majority of patients present with advanced stage disease, and recurrence after resection is common. Over the last two decades, our understanding of the molecular biology of this malignancy has increased tremendously, diagnostic techniques have evolved, and novel therapeutic approaches have been established. This review discusses the changing epidemiologic trends and provides an overview of newly identified etiologic risk factors for CCA. Furthermore, the molecular pathogenesis is discussed as well as the influence of etiology and biliary location on the mutational landscape of CCA. This review provides an overview of the diagnostic evaluation of CCA and its staging systems. Finally, new therapeutic options are critically reviewed, and future therapeutic strategies discussed.

RESULTS OF RADICAL SURGICAL TREATMENT OF CHOLANGIOCARCINOMA

Radical operations of cholangiocarcinomas are connected with the great number of post-operative complications, and lethality reaches 15-30 %. The most debatable questions remain the choice of the operation type depending on localization and spreading of a tumor and also the expedience of using mini-invasive technologies as a preoperational preparation to the radical surgical treatment. We would like to share the little experience of the radical surgical treatment of cholangiocarcinomas. The research aim is to analyze results of radical surgical treatment of patients with cholangiocarcinoma. Matherials and methods. We have analyzed the outcomes of surgical treatment in 18 patients with cholangiocarcinomas. Tumor localization was determined according to the Bismuth-Corlett classification. Type 1 tumors were found in 2 (11.1 %), type 2 in 4 (22.2 %), type 3А in 5 (27.8 %), type 3B in 4 (22.2 %), type 4 in 1 (5.6 %), and distal localization in 2 (11.1 %) patients. As biliary decompression, 9 (50 %) patients underwent percutaneous transhepatic biliary duct drainage (PTBD), and another 9 (50 %) patients were operated without preoperative biliary decompression Pre-operative embolization of portal vein branches with the aim to increase the low volume of liver after anticipated resection was performed in 4 (22.2 %) patients. Results. After the embolization of portal vein branches, the estimated residual volume of hepatic parenchyma increased from 33.4 % to 45.7 %. Patients with cholagiocarcinomas of different localization performed the radical operations: isolated hepaticocholedochus resection in 5 (27.8 %) patients, hepaticocholedochus resection combined with Taj Mahal hepatic resection in 1 (5.6 %), right hemihepatectomy in 5 (27.8 %), left hemihepatectomy in 4 (22.2 %), extended right hemihepatectomy in 1 (5.6 %), and pancreoduodenal resection in 2 (11.1 %) patients. Complications of radical surgeries were observed in 4 (22.2 %) patients. Lethal outcomes occurred in 3 (16.7 %) patients. Conclusions. Radical operations are attended with complications in 22,2 % and lethality in 16,7 %. As a preoperative preparation it is possible to use mini-invasive interventions for the biliary decompression and increase of hepatic parenchyma volume.

Pancreas-preserving resection of lower biliary tract adenocarcinoma: A coring-out technique

Surgical resection for distal cholangiocarcinoma is usually carried out using pancreaticoduodenectomy (PD). However, because PD is a complex procedure with a high rate of postoperative complications, the surgical indications should be carefully considered, especially for patients with a decreased performance status, significant comorbidities, and/or anatomical anomalies. If curatively carried out, a less invasive, local resection may be an alternative procedure for such patients. In the current study, we present pancreas‐preserving resection of the lower biliary tract in a patient with early‐stage distal cholangiocarcinoma. This procedure was selected to avoid PD with arterial reconstruction because of arterial anomalies. After an abdominal exploration, a cholecystectomy was carried out and the common hepatic duct was transected. The bile duct was dissected from the pancreatic parenchyma without pancreatic resection, downward to the biliopancreatic ductal confluence. Next, a duodenotomy was done opposite Vater's ampulla. The duodenal mucosa around Vater's ampulla was incised and dissected, and the main pancreatic duct (MPD) was divided. The bile duct was completely separated from the pancreatic parenchyma, and the lower biliary tract was totally “cored‐out”. After resection, the MPD was re‐implanted into the duodenal wall, and the duodenotomy was closed. Finally, a Roux‐en‐Y hepaticojejunostomy was created. Postoperative course was uneventful. No tumor recurrence has been observed for 21 months after the operation. Thus, pancreas‐preserving resection of the lower biliary tract appeared to be appropriate for our patient. This organ‐preserving approach can be a useful, alternative procedure in selected patients.

[Clinico-pathological factors and prognosis scale for portal cholangiocarcinoma]

INTRODUCTION

The objective of this study was to derive a prognostic scale to predict overall survival (OS) after a curative resection of perihilar cholangiocarcinoma (PHC).

MATERIAL AND METHODS

The data of 55 patients with portal cholangiocarcinoma were analysed. Patients were treated at the A.V. Vishnevsky Institute of Surgery from 2011 to 2015. Surgical treatment after biliary decompression was performed in 37 (67.3%) patients. In the long-term period we observed 36 (97.3%) of the operated patients. The dependence of the OS of clinical and pathological factors of the tumor was analysed using mono- and multifactor regression analysis of Cox proportional hazards models for all operated patients.

RESULTS

Total 1-3-, 5-year survival rate was 75.1, 60.5, 37.7, 35% respectively. Significant prognostic factors (monofactorial analysis) include perineural (p=0,05) and vascular invasion (p=0,049), R1 resection (p=0,01), disease stage III or higher (p=0,03), invasion of SI liver (p=0,004), tumor cells differentiation degree (grade) 2 and higher (p=0,0006). Multifactor analysis revealed that the low OS have determined by perineural (p=0,05) and vascular invasion (p=0,008), the degree of differentiation of tumor cells (p=0,001), disease stage (p=0,05), surgical resection margin (p=0.0345). Developed method of predicting OS is a score of prognostic factors.

CONCLUSION

The scale of individual prognosis in patients PHC takes into account both clinical and histopathological tumor characteristics. This scale may be useful to optimize the individual treatment.

DCK expression, a potential predictive biomarker in the adjuvant gemcitabine chemotherapy for biliary tract cancer after surgical resection: results from a phase II study

The role of adjuvant therapy following resection of biliary tract cancer (BTC) remains unclear. We therefore evaluated the feasibility and toxicity of adjuvant gemcitabine in patients with BTC. This clinical phase II trial was an open-label, single center, single-arm study. Within 8 weeks after gross complete resection of BTC, patients were started on intravenous infusions of gemcitabine 1000 mg/m² over 30 min on days 1, 8, and 15 of every 28-day cycle. Intratumoral expression of cytidine deaminase (CDA), human equilibrative transporter-1 (hENT1), deoxycytidine kinase (dCK) and ribonucleotide reductase subunit 1 (RRM1) was measured by immunohistochemistry. This study enrolled 72 patients with BTC (26 with gallbladder cancer, 33 with extrahepatic cholangiocarcinoma, and 13 with intrahepatic cholangiocarcinoma). The 2-year recurrence-free survival (RFS) rate was 43% (95% CI, 33–57%). Multivariable analysis showed that DCK expression, vascular invasion, and lymph node metastasis were significantly associated with RFS. Twenty-one (31.8%) were positive for DCK immunoreactivity. The median RFS was 34.95 months for DCK-positive patients, compared with 11.41 months for DCK-negative patients. Although the primary hypothesis of this study, defined as a 2-year RFS of 60%, was not met, intratumoral DCK expression was significantly associated with RFS in patients with resected BTC treated with postoperative gemcitabine chemotherapy. Future randomized controlled trials are warranted.

Neutrophil-to-lymphocyte ratio predicts prognosis after neoadjuvant chemotherapy and resection of intrahepatic cholangiocarcinoma

BACKGROUND

Previous studies have demonstrated a strong association between the preoperative neutrophil-to-lymphocyte ratio and the outcomes of patients with resected hepatocellular carcinoma and colorectal liver metastases. However, the predictive ability of neutrophil-to-lymphocyte ratio in patients with intrahepatic cholangiocarcinoma, especially those treated with preoperative chemotherapy, has been less well described.

METHODS

The clinicopathological characteristics, overall survival, and recurrence free survival of all patients with intrahepatic cholangiocarcinoma resected between 2000-2015, were compared between those with elevated (≥3.0) and normal (<3.0) neutrophil-to-lymphocyte ratio.

RESULTS

Among 119 patients who met the inclusion criteria, 64 (53.8%) had neutrophil-to-lymphocyte ratio <3.0 and 55 (46.2%) had neutrophil-to-lymphocyte ratio ≥3.0. Patients with neutrophil-to-lymphocyte ratio ≥3.0 were more likely to be female and have lymph node metastasis (P < .05). Cumulative 5-year overall survival and recurrence free survival rates were 87% and 60%, respectively in patients with neutrophil-to-lymphocyte ratio <3.0, compared with 64% and 39%, respectively in patients with neutrophil-to-lymphocyte ratio ≥3.0 (P = .049 and .038). Among 43 patients treated with preoperative chemotherapy and resection, 21 (48.8%) had neutrophil-to-lymphocyte ratio <3.0 and 22 (51.2%) had neutrophil-to-lymphocyte ratio ≥3.0. In this subgroup, cumulative 5-year overall survival and recurrence free survival rates were 95% and 70%, respectively in the patients with neutrophil-to-lymphocyte ratio <3.0 compared with 50% and 26%, respectively in the patients with neutrophil-to-lymphocyte ratio ≥3.0 (P = .002 and P = .004). On multivariate analysis, a neutrophil-to-lymphocyte ratio ≥3.0 was associated significantly with worse overall survival among all patients as well as overall survival and recurrence free survival among the subgroup who received preoperative chemotherapy.

CONCLUSION

Neutrophil-to-lymphocyte ratio is associated independently with worse survival in patients with intrahepatic cholangiocarcinoma undergoing resection or neoadjuvant chemotherapy prior to resection.

Survival outcome and prognostic factors after pancreatoduodenectomy for distal bile duct carcinoma: a retrospective multicenter study

PURPOSE

Pancreatoduodenectomy is the most common operative procedure performed for distal bile duct carcinoma. Data on outcome after surgery for this rare malignancy is scarce, especially from western countries. The purpose of this study is to explore the prognostic factors and outcome after pancreatoduodenectomy for distal bile duct carcinoma.

METHODS

Patients receiving pancreatoduodenectomy for distal bile duct carcinoma were identified from institutional databases of five German and one Russian academic centers for pancreatic surgery. Univariable and multivariable general linear model, Kaplan-Meier method, and Cox regression were used to identify prognostic factors for postoperative mortality and overall survival.

RESULTS

N = 228 patients operated from 1994 to 2015 were included. Reoperation (OR 5.38, 95%CI 1.51-19.22, p = 0.010), grade B/C postpancreatectomy hemorrhage (OR 3.73, 95%CI 1.13-12.35, p = 0.031), grade B/C postoperative pancreatic fistula (OR 4.29, 95%CI 1.25-14.72, p = 0.038), and advanced age (OR 4.00, 95%CI 1.12-14.03, p = 0.033) were independent risk factors for in-hospital mortality in multivariable analysis. Median survival was 29 months, 5-year survival 27%. Positive resection margin (HR 2.07, 95%CI 1.29-3.33, p = 0.003), high tumor grade (HR 1.71, 95%CI 1.13-2.58, p = 0.010), lymph node (HR 1.68, 95%CI 1.13-2.51, p = 0.011), and distant metastases (HR 2.70, 95%CI 1.21-5.58, p = 0.014), as well as severe non-fatal postoperative complications (HR 1.64, 95%CI 1.04-2.58, p = 0.033) were independent negative prognostic factors for survival in multivariable analysis.

CONCLUSION

Distant metastases and positive resection margin are the strongest negative prognostic factors for survival after pancreatoduodenectomy for distal bile duct carcinoma; thus, surgery with curative intent is only warranted in patients with local disease, where R0 resection is feasible.

Intranuclear accumulation of galectin-3 is an independent prognostic factor for patients with distal cholangiocarcinoma

Galectin-3 has been reported to be associated with the prognosis of patients with various malignancies; however, it has not yet been investigated in patients with extrahepatic cholangiocarcinoma (EHCC). Expression of galectin-3 was retrospectively examined in 58 patients with EHCC: 21 with perihilar cholangiocarcinoma and 37 with distal cholangiocarcinoma (DCC). The Cox proportional hazard model was used to identify independent prognostic factors. Intranuclear accumulation of galectin-3 (gal-3-INA) was associated with poorer overall survival (OS) in all patients (P=0.003), as well as in patients with DCC (P=0.004). Patients with gal-3-INA also exhibited a poorer disease-free survival (DFS) than those without gal-3-INA in all patients with EHCC (P<0.001), and in patients with DCC (P<0.001). Gal-3-INA was an independent prognostic factor of OS and DFS in all patients [OS: Hazard ratio (HR), 4.470; 95% confidence interval (CI), 1.759–11.357; P=0.002; and DFS: HR, 5.116; 95% CI, 2.025–12.925; P=0.001]. Gal-3-INA was also an independent prognostic factor in patients with DCC (OS: HR, 2.979; 95% CI, 1.035–8.570; P=0.043; and DFS: HR, 6.773; 95% CI, 1.558–29.439; P=0.011). In the analysis of patients with DCC, the number of patients with high galectin-3 expression (P=0.038), recurrence (P<0.001), distant metastases (P<0.001), R0 status (P=0.029) or microscopic vascular invasion (P=0.019) was significantly higher in the gal-3-INA-positive group than in the gal-3-INA-negative group. In conclusion, gal-3-INA was identified as a strong prognostic factor for OS and DFS in patients with DCC.

Surgical options for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer, accounting for 10-15% of primary hepatic malignancy. The incidence and cancer-related mortality of ICC continue to increase worldwide. At present, hepatectomy is still the most effective treatment for ICC patients to achieve long-term survival, although its overall efficacy may not be as good as that for patients with hepatocellular carcinoma (HCC) due to the unique pathogenesis and clinical-pathological profiles of ICC. Viral infection, lithiasis and metabolic factors may all be associated with the pathogenesis of ICC. Poor blood supply, cirrhosis (in rare cases), surrounding organ invasion, and lymph node/distal metastasis have significant impacts on the selection of surgical strategies, surgical resection rate, postoperative complications, recurrence and metastasis. Surgical treatment for ICC includes R0 resection, lymphadenectomy, total gross resection of the involved biliary tracts, blood vessels and surrounding tissues in adjacent organs, and reconstruction. Postoperative adjuvant therapy and local-regional therapy after recurrence may improve survival. Liver transplantation (LT) is reported to have a moderate treatment effect on early ICC although its efficacy remains controversial. In this article, we reviewed the epidemiology and staging of ICC and highlighted the selection of surgical modalities and postoperative outcomes of ICC patients via literature review.

Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

BACKGROUND

Distal cholangiocarcinomas and pancreatic cancers both arise from pancreaticobiliary epithelium. Despite their common origin, there is a possible discrepancy in outcome. We analysed the surgical, pathological and survival outcome of resected distal cholangiocarcinoma compared with pancreatic cancer.

METHODS

All cases of resected distal cholangiocarcinoma and pancreatic cancer from 1998 to 2014 were extracted from our database. Outcomes were compared.

RESULTS

There were 54 (7.6%) cases of cholangiocarcinoma and 656 (92.4%) pancreatic cancer. Cholangiocarcinoma showed lower T and N stage, lymphatic and perineural invasion (p < 0.05), worse surgical outcome (p < 0.05) and less access to adjuvant therapy if compared with pancreatic cancer (72.7 vs. 83.1%, p = 0.05). Both showed a similar disease-specific survival (35 vs. 29 months, p = 0.3). Independent predictors of prognosis for pancreatic cancer were resection margin, grading, perineural invasion, T and N status, whereas for cholangiocarcinoma were grading and occurrence of POPF.

CONCLUSION

Considering a large cohort of resected periampullary cancers, cholangiocarcinoma is extremely rare. An earlier diagnosis is associated with better pathological predictors of outcome but increased postoperative morbidity compared to pancreatic cancer, particularly POPF. Consequent decrease in the access to adjuvant therapy for complicated cholangiocarcinoma might explain why survival is as poor as for pancreatic cancer.

Cholangiocarcinoma

Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis. The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.

Resection margin influences survival after pancreatoduodenectomy for distal cholangiocarcinoma

INTRODUCTION

Distal cholangiocarcinoma remains a rare cancer associated with a dismal outcome. There is a lack of effective treatment options and where disease is amendable to resection, surgery affords the best potential for long-term survival. The aim of this study was to examine the survival outcomes and prognostic factors of patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma.

METHODS

Between January 2004 to May 2016, patients who had undergone pancreatoduodenectomy with histologically proven distal cholangiocarcinoma were identified. Clinicopathologic data and survival outcomes were reported.

RESULTS

Pancreatoduodenectomy alone was performed in 20 patients (71%) and eight patients (29%) required concomitant vascular resection. The major complication rate was 43% (n = 12). Nineteen patients (68%) had node positive disease. Eighteen patients (64%) had R0 resection. The median survival was 36 months (95%CI 9.7 to 63.8) and 5-year survival rate was 24%. Univariate analysis identified ASA (P < 0.001), tumor grade (P = 0.009) and margin status (P = 0.042) as prognostic factors associated with survival.

CONCLUSION

Long-term survival may be achieved in selected patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma, especially in patients who achieved an R0 resection.

Is There a Role for Adjuvant Therapy in R0 Resected Gallbladder Cancer?: A Propensity Score-Matched Analysis

PURPOSE

The purpose of this study is to assess the role of adjuvant therapy in stage I-III gallbladder cancer (GBC) patients who have undergone R0 resection.

MATERIALS AND METHODS

Clinical data were collected on 441 consecutive patients who underwent R0 resection for stage I-III GBC. Eligible patients were classified into adjuvant therapy and surveillance only groups. Propensity score matching (PSM) between the two groups was performed, adjusting clinical factors.

RESULTS

In total, 84 and 279 patients treated with adjuvant therapy and followed up with surveillance only, respectively, were included in the analysis. Before PSM, the 5-year relapse-free survival (RFS) rate was lower in the adjuvant therapy group than in the surveillance only group (50.8% vs. 74.8%, p < 0.001), although there was no statistically significant difference in the 5-year overall survival (OS) rate (66.2% vs. 79.5%, p=0.089). After the PSM, baseline characteristics became comparable and there were no differences in the 5-year RFS (50.8% vs. 64.8%, p=0.319) and OS (66.2% vs. 70.4%, p=0.703) rates between the two groups.

CONCLUSION

The results suggest that fluoropyrimidine-based adjuvant therapy is not indicated in stage I-III GBC patients who have undergone R0 resection.

Impact of EUS-FNA for preoperative para-aortic lymph node staging in patients with pancreatobiliary cancer

BACKGROUND AND AIMS

In patients with pancreatobiliary cancer, para-aortic lymph node (PALN) metastasis is considered to be the involvement beyond the regional lymph nodes, namely, distant metastasis. Effective methods for preoperative PALN staging, however, are not established. This study aimed to compare the diagnostic capability for PALN metastasis between EUS-FNA and (18)F-fluorodeoxyglucose positron emission tomography with CT (PET/CT).

METHODS

We performed a prospective, nonrandomized, single-center trial. Between December 2010 and March 2014, 208 patients with pancreatobiliary cancer without apparent distant metastasis except for PALNs were assessed for study eligibility before surgery. Among them, 52 consecutive patients with PALN enlargement were enrolled in the study. (18)F-Fluorodeoxyglucose PET/CT and EUS-FNA were performed sequentially as a single combined procedure to evaluate PALN metastases. The primary outcome was to compare the diagnostic capability of EUS-FNA and PET/CT for PALN metastasis.

RESULTS

Of 71 enlarged PALNs in the 52 patients, 30 (42.3%) were finally diagnosed as metastases in 21 patients (40.4%). Of the 21 patients with PALN metastases, preoperative EUS-FNA or PET/CT made a correct diagnosis in 20 (95.2%) or 12 (57.1%), respectively. EUS-FNA had higher sensitivity and specificity for the diagnosis of PALN metastasis (sensitivity, 96.7% [29/30]; 95% confidence interval, 82.2%-99.9%; specificity, 100% [39/39]; 95% confidence interval, 91.0%-100%) than PET/CT.

CONCLUSIONS

EUS-FNA is superior to PET/CT for preoperative PALN staging in patients with pancreatobiliary cancer. Because of the clinical benefit of EUS-FNA to reduce unnecessary surgery, it should be part of the standard preoperative examination for patients with pancreatobiliary cancer. (UMIN clinical trials registry number: 000006408.).

The pathways of genetic transformation in cholangiocarcinogenesis

Cholangiocarcinoma (CCA) is an aggressive malignancy that originates from the epithelial cells of the biliary duct system. Depending on the anatomical location, CCA can be considered extrahepatic (eCCA) or intrahepatic (iCCA) (1). Two thirds of CCAs involve the extrahepatic biliary system, whereas the rest are confined within the liver parenchyma, beyond the secondary biliary radicals (2). Due to its biological aggressiveness and difficulty in diagnosis, the majority of patients with CCA are unresectable at presentation and the overall 5-year survival is approximately five percent (4). This article focuses on the genetic and epigenetic alterations present in cholangiocarcinomas, their occasional relationship to external stimuli, and with an emphasis on those unanswered questions about cholangiocarcinogenesis and future directions in the comprehension of epigenetic DNA methylation in patients with CCA.

Relationship between the surgical margin status, prognosis, and recurrence in extrahepatic bile duct cancer patients

PURPOSE

The purpose of this retrospective study was to evaluate the relationship between the surgical margin status of the bile duct and the prognosis and recurrence of extrahepatic bile duct (EHBD) cancer.

METHODS

The clinical data of 100 patients who underwent surgery for EHBD cancer between February 2002 and September 2014 were analyzed. The ductal margin status was classified into the following three categories: negative (D-N), positive with carcinoma in situ (D-CIS), and positive with invasive carcinoma (D-INV).

RESULTS

The number of patients with D-N, D-CIS, and D-INV was 69, 16, and 15, respectively. Local recurrence rates of patients with D-CIS (56.3 %) and D-INV (66.7 %) were significantly higher compared to those of patients with D-N (10.1 %; P < 0.001). D-CIS was a significant predictor of shorter recurrence-free survival (RFS). Lymph node metastasis (P = 0.037) and D-INV (P = 0.008) were independent predictors of shorter disease-specific survival (DSS). The prognostic relevance of the ductal margin status was high, particularly in patients without lymph node metastasis.

CONCLUSION

The surgical margin status of the bile duct was significantly associated with RFS, DSS, and the recurrence site.

Significance of Vascular Resection and Reconstruction in Surgery for Hilar Cholangiocarcinoma: With Special Reference to Hepatic Arterial Resection and Reconstruction

PURPOSE

The aim of this study was to assess the efficacy of combined resection and reconstruction (CRR) of the hepatic artery (HA) in surgery for hilar cholangiocarcinoma (HC).

MATERIALS AND METHOD

Among 172 patients who underwent surgical resection for HC, the following three groups were defined according to the type of vascular reconstruction: VR(-) group, in which neither CRR of the portal vein (PV) nor HA was performed (n = 74); VR-PV group, in which only CRR of the PV was required (n = 54); and VR-A group, in which CRR of the HA was performed either with or without CRR of the PV (n = 44). Clinicopathological variables and clinical outcomes were compared among the three groups.

RESULTS

Although the VR-A group showed significantly more advanced disease than other groups, the R0 resection rate was comparable among the three groups (VR(-), 74 %; VR-PV, 80 %; VR-A, 80 %). The 5-year disease-specific survival rate was also comparable among the three groups (VR(-), 45.6 %; VR-PV, 51.2 %; VR-A, 22.3 %), but tended to be worse in the VR-A group than in the other groups. A similar trend was observed in morbidity rate. Lymph node metastasis was more frequent in the VR-A group (59 %) than in the other groups (VR(-), 33.8 %; VR-PV, 50 %). In the VR-A group, lymph node metastasis (p = 0.004) and adjuvant chemotherapy (p = 0.006) were determined to represent independent prognostic factors for survival according to multivariate analysis.

CONCLUSION

CRR of the HA was considered efficacious in selected patients; however, long-term outcomes of the VR-A group seem unsatisfactory. Treatments additional to surgery may be necessary in cases requiring CRR of the HA.