Liver transplantation for cholangiocarcinoma: results in 207 patients

Prognostic analysis of surgical treatment of peripheral cholangiocarcinoma: Two decades of experience at Chang Gung Memorial Hospital

AIM: To analyze the prognostic factors influencing the overall survival of peripheral cholangiocarcinoma (PCC) patients undergoing surgical treatment during 25 years at a single institution.

METHODS: This study retrospectively reviewed prospectively collecting data about 373 patients with histologically proven PCC who underwent surgical treatment between 1977 and 2001.

RESULTS: Three hundred and seventy-three PCC patients (159 men and 214 women) underwent surgical treatment from 1977 to 2001. Among them, 187 PCC patients underwent hepatectomy and 135 had curative resection (curative resectability rate: 36.2%). The follow-up duration ranged from 1.05 to 167.6 mo (mean/median = 14.1/7.2 mo). Overall cumulative survival rates at 1, 3, and 5 years were 32.5%, 9.2%, and 4.1%, respectively. Univariate log-rank analysis identified the following as adverse influences on overall survival: presence of symptoms, absence of mucobilia, elevated CEA and CA 19-9 levels, non-papillary tumor type, receiving non-hepatectomy, advanced tumor staging, lack of post-operative chemotherapy, and radiotherapy. Meanwhile, multivariate Cox’s proportional hazard analysis demonstrated that absence of mucobilia, non-papillary tumor type, advanced tumor staging, non-hepatectomy, and lack of post-operative chemotherapy were the five independent prognostic factors that adversely affected overall survival.

CONCLUSION: Favorable overall survival of PCC patients undergoing surgical treatment depends on early tumor stage, presence of mucobilia, papillary tumor type, hepatic resection, and post-operative chemotherapy.

Living donor liver transplant for malignancy

Adult-to-adult living donor liver transplantation (ALDLT) is being increasingly utilized to treat patients with locally advanced hepatocellular carcinoma and cholangiocarcinoma who are not prioritized under the MELD allocation system. A single institution retrospective chart review examined ALDLTs performed for malignancy to identify indications, complications, and transplant outcome. Since 1997, 18 ALDLTs have been performed for malignancy as the primary indication. Thirteen patients were transplanted for HCC. The median survival following transplant was 18.6 months and four patients developed recurrent HCC. Five patients were transplanted for cholangiocarcinoma, with a 100% recurrence free survival at a mean follow up of 18 months among patients given neo-adjuvant chemoradiation. ALDLT can be safely performed for malignancy with an acceptable peri-operative mortality rate. However, HCC patients with large tumors experience a high rate of recurrence. The use of ALDLT for cholangiocarcinoma appears promising specifically in the context of neo-adjuvant therapy.

Extended hepatectomy for intrahepatic cholangiocellular carcinoma (ICC): when is it worthwhile? Single center experience with 27 resections in 50 patients over a 5-year period

OBJECTIVE

To evaluate the role of extended hepatectomy in locally advanced intrahepatic cholangiocarcinoma (ICC).

SUMMARY BACKGROUND DATA

ICC is a rare tumor which has to be clearly distinguished from hepatocellular carcinoma and extrahepatic bile duct carcinoma. It is believed that long-term survival can only be achieved by surgical resection.

METHODS

Between April 1998 and March 2003, 50 patients with locally advanced ICC (tumor involvement of more than 4 liver segments) underwent surgical exploration. Data were analyzed with regard to patients' characteristics, intraoperative details, pathologic findings, and outcome measured by tumor recurrence, treatment of recurrence, and survival.

RESULTS

Resectability rate was 27 of 50 (54%). There were 19 extended right and 8 extended left hepatectomies. In addition, in 16 patients the following 29 procedures were performed: resection of hilar bifurcation (n = 12), partial resection of diaphragm (n = 6), partial resection of vena cava (n = 4), resection and reinsertion of left liver vein (n = 1), portal vein resection (n = 5), resection and reconstruction of right hepatic artery (n = 1). Complete tumor removal (R0-resection) was achieved in 16 patients. In 11 cases, there was microscopic tumor at the cutting margin (R1-resection). Following resection, the overall 1- and 3-year-survival rates were 69% and 55%. After R1-resection and explorative laparotomy, median survival was 5 and 7 months, respectively. Following R0-resection, the calculated median survival and 1- and 3-year-survival rates are 46 months, 94% and 82% (P = 0.0039; log-rank test). Tumor recurred in 6 of 16 patients, and so far 2 patients died of recurrence 28 and 46 months after operation.

CONCLUSIONS

R0-resection can provide prolonged survival, even in patients with advanced ICC. In particular in solitary tumors without vascular invasion (UICC stage I, sixth classification) there is a major chance for long-term survival and cure. The poor results after R1-resection and the high operative morbidity do not justify palliative resections but underline the need for an improved preoperative assessment of resectability, as well as an aggressive intraoperative approach, to achieve complete tumor resection.

Phase II study of hepatic intraarterial epirubicin and cisplatin, with systemic 5-fluorouracil in patients with unresectable biliary tract tumors

BACKGROUND

Patients with unresectable biliary tract carcinomas have a very poor prognosis. To improve the efficacy and tolerance of the ECF regimen (epirubicin at a dose of 50 mg/m2, cisplatin at a dose of 60 mg/m2, and 5-fluorouracil [5-FU] at a dose of 200 mg/m2 per day by continuous infusion), the authors designed a novel approach that combined locoregional and systemic chemotherapy with the same agents at the same dosages.

METHODS

Thirty consecutive patients with advanced or metastatic biliary tumors were treated with epirubicin at a dose of 50 mg/m2 and cisplatin at a dose of 60 mg/m2 administered as a bolus in the hepatic artery on Day 1, combined with systemic continuous infusion of 5-FU at a dose of 200 mg/m2 per day, from Day 1 to Day 14, every 3 weeks.

RESULTS

Tumor sites were the intrahepatic bile ducts in 25 patients and the gallbladder in 5 patients. The overall response rate was 40% (12 of 30 patients), including 1 complete response and 11 partial responses. Stable disease was observed in 12 of 30 patients (40%) and progressive disease in 6 of 30 patients (20%). The median progression-free and overall survival periods were 7.1 and 13.2 months, respectively, and the 1-year and 2-year survival rates were 54% and 20%, respectively. Performance status improved in 9 of 30 patients (30%) and a weight gain of > 7% was observed in 4 of 30 patients (13%). The treatment was well tolerated with minimal hematologic toxicity. The major clinical problem was the deep venous thrombosis related to the central venous catheter, which occurred in 5 patients (17%).

CONCLUSIONS

This novel combined locoregional and systemic chemotherapeutic regimen was found to be active and safe for patients with advanced biliary tract carcinoma.

[Intra-hepatic cholangiocarcinoma]

Intra-hepatic cholangiocarcinoma (IHCC) is a rare tumor which arises from the epithelial cells of the intra-hepatic bile ducts; it may develop in a healthy liver and bile ducts or in bile ducts with malignant predisposition (Caroli's syndrome, primary sclerosing cholangitis). It has the worst prognosis of any tumor arising in the liver. Unlike hepatocellular carcinoma, no predisposing factors or high-risk populations have been demonstrated for cholangiocarcinoma other than intraphepatic choledocholithiasis such as is seen in east Asian populations. The most common clinical sign is a palpable tumor mass emphasizing that the tumor is usually detected at an advanced stage. CT scanning yields much clinical information but ultrasound-guided needle biopsy is necessary for diagnosis. Aggressive surgical resection is the only treatment modality which has afforded even slight prolongation of survival; hepatic resection must be large with uninvolved resection margins. When an IHCC is deemed resectable (localized tumor without hepatic metastases or intrahepatic or extrahepatic lymph node spread), pre-operative tumor embolization may be useful; when jaundice is present, percutaneous drainage of the dilated biliary system of the liver to be spared may also be necessary. Neither adjuvant nor neo-adjuvant chemotherapy or radiotherapy have shown proof of efficacity. Cholangiocarcinoma complicates sclerosing cholangitis in 10-15% of cases and is very difficult to diagnose. IHCC may also develop in Caroli's syndrome, where it is commonly found incidentally on pathologic examination of a resection specimen after surgery for a complication of the disease.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the intra- and extrahepatic bile ducts. An estimated 80% of patients in North America and Europe have coexistent inflammatory bowel disease (IBD). The underlying pathophysiology of PSC remains poorly understood. As a result, there is currently no effective medical therapy to halt disease progression. Important complications from PSC include metabolic bone disease, colorectal neoplasia, and cholangiocarcinoma. Liver transplantation remains the only successful treatment option for patients with advanced liver disease from PSC. A diagnosis of PSC should be considered among individuals with IBD and elevated serum liver biochemical tests.

The role of liver transplantation in the treatment of hilar cholangiocarcinoma

Surgical resection or liver transplantation (LTx) are the only available treatments that offer a potential for long-term survival or cure in cases of hilar cholangiocarcinoma. Hilar resection in combination with partial hepatectomy and caudate lobectomy is regarded as the current treatment of choice. Overall 5-year survival rates range from 9% to 28%, and reach as high as 24-43% in R0 resections. Five-year survival rates in the very limited experience with LTx in hilar cholangiocarcinoma are not dramatically worse than those after resection. However, hilar cholangiocarcinoma is not at present an accepted indication for LTx given both the good results of LTx for benign diseases and the dramatic organ shortage. When compared with the prognosis of other gastrointestinal tumours, these survival rates are encouraging in the setting of an otherwise unresectable malignancy. As such, and considering the fact that it may represent the only possibility for cure, the general exclusion of patients with cholangiocarcinomas as candidates for LTx does not seem to be justified. Furthermore, recent advances in multimodal tumour therapy seem to be most promising in combination with LTx. Prospective studies are required to elucidate the influence of better patient selection and the role of multimodal treatments on the outcome of LTx in hilar cholangiocarcinoma. If the encouraging data achieved with neoadjuvant therapy prior to LTx are confirmed by further studies, we foresee that renewed interest in LTx for hilar cholangiocarcinoma could arise.

Role of liver transplantation for hepatobiliary malignant disorders

The role of liver transplantation for hepatobiliary malignant disorders remains controversial and will remain so until several crucial issues are resolved, the main difficulty being the shortage of organ donors. Furthermore, a consensus needs to be reached within the transplantation community on the tumour stage at which each disorder is too advanced to be salvaged by liver transplantation. Despite these limitations, there are generally accepted criteria that define when transplantation can, and should, be offered for hepatobiliary malignant disorders.

Diagnosis and treatment of cholangiocarcinoma

Cholangiocarcinoma presents a formidable diagnostic and treatment challenge. The majority of patients present with unresectable disease and have a survival of less than 12 months following diagnosis. Progress has been made by the appropriate selection of patients for treatment options including resection, with the routine use of more aggressive resections in order to achieve margin-negative resections. This has resulted in longer survival times for these patients. Neoadjuvant and adjuvant therapies have, for the most part, not improved survival in patients with this tumor, and new strategies are needed to improve this line of therapy. The prognosis for unresectable patients is poor, and palliative measures should be aimed at increasing quality of life first and increasing survival second.

Rapamycin protects allografts from rejection while simultaneously attacking tumors in immunosuppressed mice

Cancer is an increasingly recognized problem associated with immunosuppression. Recent reports, however, suggest that the immunosuppressive agent rapamycin has anti-cancer properties that could address this problem. Thus far, rapamycin's effects on immunity and cancer have been studied separately. Here we tested the effects of rapamycin, versus cyclosporine A (CsA), on established tumors in mice simultaneously bearing a heart allograft. In one tumor-transplant model, BALB/c mice received subcutaneous syngenic CT26 colon adenocarcinoma cells 7 days before C3H ear-heart transplantation. Rapamycin or CsA treatment was initiated with transplantation. In a second model system, a B16 melanoma was established in C57BL/6 mice that received a primary vascularized C3H heart allograft. In vitro angiogenic effects of rapamycin and CsA were tested in an aortic ring assay. Results show that CT26 tumors grew for 2 weeks before tumor complications occurred. However, rapamycin protected allografts, inhibited tumor growth, and permitted animal survival. In contrast, CsA-treated mice succumbed to advancing tumors, albeit with a functioning allograft. Rapamycin's antitumor effect also functioned in severe combined immunodeficient BALB/c mice. Similar effects of the drugs occurred with B16 melanomas and primary vascularized C3H allografts in C57BL/6 mice. Furthermore, in this model, rapamycin inhibited the tumor growth-enhancing effects of CsA. Moreover, in vitro experiments showed that CsA promotes angiogenesis by a transforming growth factor-beta-related mechanism, and that this effect is abrogated by rapamycin. This study demonstrates that rapamycin simultaneously protects allografts from rejection and attacks tumors in a complex transplant-tumor situation. Notably, CsA protects allografts from rejection, but cancer progression is promoted in transplant recipients.

Hepatoma—resection or transplantation

The most frequent tumors of the liver originate from the hepatocytes, bile duct epithelium, and endothelial cells. Hepatocellular carcinoma accounts for 80% to 90% of primary liver cancer. Cholangiocarcinoma, a neoplasm that arises from the biliary tree, is the second most common primary hepatic malignancy. This article deals with the epidemiology and clinical presentation and the diagnostic confirmation and classification of both conditions, and with the use of liver resection and transplanation treatment for both.

Diagnosis and treatment of cholangiocarcinoma

Epidemiologic studies have demonstrated increasing mortality rates from intrahepatic cholangiocarcinoma during the past decades. Primary sclerosing cholangitis is the most important predisposing condition to the development of cholangiocarcinoma. Improvements in noninvasive diagnostic techniques have led to decreased use of invasive procedures. Magnetic resonance imaging (MRI) has the potential to depict parenchymal, ductal, and vascular tumor involvement. However, diagnosis can be difficult, and often ultrasonography, MRI, CT, and invasive cholangiography are complementary investigations. Genetic aberrations in brush cytology specimens should be explored further in prospective studies. Endoscopic ultrasonography, intraductal ultrasonography, and positron emission tomography are interesting techniques that are under evaluation. Radical surgery with negative histologic margins is the only curative option in cholangiocarcinoma. With more aggressive surgical approaches, including partial hepatectomy, 3-year survival rates of 35% to 50% can be achieved. Liver transplantation for unresectable cholangiocarcinoma was shown to be feasible in pilot studies of highly selected patients.

Spanish experience in liver transplantation for hilar and peripheral cholangiocarcinoma

OBJECTIVE

To assess the real utility of orthotopic liver transplantation (OLT) in patients with cholangiocarcinoma, we need series with large numbers of cases and long follow-ups. The aim of this paper is to review the Spanish experience in OLT for hilar and peripheral cholangiocarcinoma and to try to identify the prognostic factors that could influence survival.

SUMMARY BACKGROUND DATA

Palliative treatment of nondisseminated irresectable cholangiocarcinoma carries a zero 5-year survival rate. The role of OLT in these patients is controversial, due to the fact that the survival rate is lower than with other indications for transplantation and due to the lack of organs.

METHODS

We retrospectively reviewed 59 patients undergoing OLT in Spain for cholangiocarcinoma (36 hilar and 23 peripheral) over a period of 13 years. We present the results and prognostic factors that influence survival.

RESULTS

The actuarial survival rate for hilar cholangiocarcinoma at 1, 3, and 5 years was 82%, 53%, and 30%, and for peripheral cholangiocarcinoma 77%, 65%, and 42%. The main cause of death, with both types of cholangiocarcinoma, was tumor recurrence (present in 53% and 35% of patients, respectively). Poor prognosis factors were vascular invasion (P < 0.01) and IUAC classification stages III-IVA (P < 0.01) for hilar cholangiocarcinoma and perineural invasion (P < 0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma.

CONCLUSIONS

OLT for nondisseminated irresectable cholangiocarcinoma has higher survival rates at 3 and 5 years than palliative treatments, especially with tumors in their initial stages, which means that more information is needed to help better select cholangiocarcinoma patients for transplantation.

The immunosuppressive drug mycophenolate mofetil impairs the adhesion capacity of gastrointestinal tumour cells

Immunosuppression correlates with the development and recurrence of cancer. Mycophenolate mofetil (MMF) has been shown to reduce adhesion molecule expression and leucocyte recruitment into the donor organ. We have hypothesized that MMF might also prevent receptor-dependent tumour dissemination. Therefore, we have investigated the effects of MMF on tumour cell adhesion to human umbilical vein endothelial cells (HUVEC) and compared them with the effects on T cell-endothelial cell interactions. Influence of MMF on cellular adhesion to HUVEC was analysed using isolated CD4+ and CD8+ T cells, or WiDr colon adenocarcinoma cells as the model tumour. HUVEC receptors ICAM-1, VCAM-1, E-selectin and P-selectin were detected by flow cytometry, Western blot or Northern blot analysis. Binding activity of T cells or WiDr cells in the presence of MMF were measured using immobilized receptor globulin chimeras. MMF potently blocked both T cell and WiDr cell binding to endothelium by 80%. Surface expression of the endothelial cell receptors was reduced by MMF in a dose-dependent manner. E-selectin mRNA was concurrently reduced with a maximum effect at 1 microm. Interestingly, MMF acted differently on T cells and WiDr cells. Maximum efficacy of MMF was reached at 10 and 1 microm, respectively. Furthermore, MMF specifically suppressed T cell attachment to ICAM-1, VCAM-1 and P-selectin. In contrast, MMF prevented WiDr cell attachment to E-selectin. In conclusion, our data reveal distinct effects of MMF on both T cell adhesion and tumour cell adhesion to endothelial cells. This suggests that MMF not only interferes with the invasion of alloactivated T cells, but might also be of value in managing post-transplantation malignancy.

Liver transplantation for primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease that progresses to end-stage liver disease. This report is a retrospective analysis of a Canadian centre experience with liver transplantation (LT) for PSC. Of 1107 LTs performed between 1984 and 2002, 132 were performed on 111 patients with PSC. Patient survival at 1, 3, 5, and 10 years was 84.5%, 84.5%, 83.4%, and 68.9%, respectively. Graft survival at 1, 3, 5, and 10 years was 80.8%, 79.8%, 72.7%, and 55.3%. These were not significantly different from overall patient survival (P =.91) or graft survival (P =.28) in non-PSC patients transplanted over the same time period. Early mortality was predominantly related to primary nonfunction and multi-organ failure; late mortality was predominantly related to malignancy. No patient with known cholangiocarcinoma (CCA) underwent LT, but three patients had an incidental CCA noted on explant pathology. All three died of widespread metastatic disease (10.8, 38.0, and 39.8 months after LT). Nineteen patients lost their primary grafts requiring retransplantation, and two of these patients required a third transplant. Recurrent PSC was detected in six patients and suspected in another six. Four patients have been retransplanted for recurrent PSC. Chronic rejection was detected in nine patients. Eight have required retransplantation. The incidence of biliary complications was 16.2%.

CONCLUSIONS

LT is effective therapy for PSC. Patient and graft survival is comparable to that seen in patients transplanted for indications other than PSC, but long-term graft survival may be lower. Recurrent PSC and chronic rejection are the major determinants of graft loss.

US of liver transplants: normal and abnormal

Whole-liver transplantation is an accepted and successful method of treating end-stage liver disease. As a result of the shortage of cadaveric livers, split-liver transplantation and living donor liver transplantation are becoming more commonplace. Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. Biliary complications include leaks, strictures, stones or sludge, dysfunction of the sphincter of Oddi, and recurrent disease. Neoplastic disease in the transplanted liver may represent recurrent neoplasia or posttransplantation lymphoproliferative disorder. Parenchymal disease may take the form of a focal mass or a diffuse parenchymal abnormality. Perihepatic fluid collections and ascites are common after liver transplantation. Knowledge of the surgical technique of liver transplantation and awareness of the normal US appearance of the transplanted liver permit early detection of complications and prevent misdiagnosis.

Liver transplantation for peripheral cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated unresectable peripheral cholangiocarcinoma (PCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than with other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for PCC to identify prognostic factors for survival.

METHODS

We retrospectively reviewed 23 patients undergoing OLT in Spain for PCC over a period of 13 years.

RESULTS

The actuarial survival rates were 77%, 65%, and 42% at 1, 3, and 5 years, respectively. The main cause of death was tumor recurrence (35%). Prognotic factors for an adverse outcome were pTNM classification (P<.05) in the univariate analysis and perineural invasion (P<.05) and stages III or IVA (P<.05) in the multivariate analysis.

CONCLUSIONS

OLT for nondisseminated irresectable PCC displays higher survival rates at 3 and 5 years than palliative treatments, especially for tumors in the initial stages, which means that more information is needed to help better select PCC patients for transplantation.

Liver transplantation for hilar cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated irresectable hilar cholangiocarcinoma (HCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than that for other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for HCC and identify prognostic factors for survival.

METHODS

We retrospectively reviewed 36 patients undergoing OLT for HCC over 13 years.

RESULTS

The actuarial survival rate at 1, 3, and 5 years was 82%, 53%, and 30%, respectively. The main cause of death was tumor recurrence (53%). In the univariate analysis, the factors for a poor prognosis were vascular invasion (P<.001) namely 0% survival at 3 years when present versus 63% and 35% at 3 and 5 years, respectively, when it was not; and stages III to IVA (P<.05), namely 15% survival at 5 years versus 47% for stages I to II. Lymph node and perineural invasion also reduce survival. In the multivariate analysis, the factors for poor prognosis included vascular invasion (P<.01) and stages III to IVA (P<.01).

CONCLUSION

OLT for nondisseminated irresectable HCC has higher survival rates at 3 and 5 years than palliative treatments, especially with initial stage tumors, which means that more information is needed to better select cholangiocarcinoma patients for transplantation.

The Longest Survivor and First Potential Cure of an Advanced Cholangiocarcinoma by Ex Vivo Resection and Autotransplantation: A Case Report and Review of the Literature

Bismuth type IV hilar cholangiocarcinoma (CC) carries a poor prognosis; however, ex vivo liver resection and autotransplantation (Atx) is theoretically a treatment option. There are only five previously reported cases of this procedure for hilar CC in the English literature, and most of them died early in the postoperative period. The only reported survivor died of tumor recurrence at 13 months. We are reporting a patient who has survived for 17 months without any sign of tumor recurrence. This probably represents the world's first cure for CC using this technique. This patient is a 26-year-old woman with a Bismuth Type IV CC. Portal vein involvement at the confluence was shown on angiogram, and in situ resection was deemed impossible. Ex vivo resection of segments five, six, seven, eight, and part of segment four was performed followed by a partial liver Atx. The pathology specimen demonstrated CC with clear margins. MRI and CT examinations done over the subsequent 17 months showed no evidence of recurrence. In conclusion ex vivo liver resection and Atx can be a viable option for cure among highly selected patients with CC.

Preliminary experience with liver transplantation in selected patients with unresectable hilar cholangiocarcinoma

Previous experience with OLT for hilar CCA has been discouraging, and survival was dismal. This study demonstrates that carefully selected patients with unresectable hilar CCA can achieve long-term survival after OLT. The survival rate obtained with this protocol (5-year actuarial survival of 87%) is comparable with the overall survival rate of liver-transplant recipients at the authors' institution. In comparison, the best survival rate after OLT for hilar CCA reported in the literature is 64.8% at 5 years in a subset of nine patients with negative lymph nodes. In the absence of a control group, it is difficult to assess with certainty the role of a combination of chemotherapy and radiotherapy, but in some patients it seems to prevent or slow progression of the disease while waiting for an available organ. Treatment-related morbidity, although significant, is not prohibitive. Nevertheless, a considerable proportion of treated patients ultimately was found to have advanced disease precluding transplantation. This finding confirms the importance of the staging laparotomy as an essential component of the protocol.

Optimization of 5-fluorouracil (5-FU)/cisplatin combination chemotherapy with a new schedule of leucovorin, 5-FU and cisplatin (LV5FU2-P regimen) in patients with biliary tract carcinoma

BACKGROUND

Unresectable biliary tract carcinoma (BTC) is associated with a very poor prognosis. To improve efficacy and tolerance of the 5-fluorouracil (5-FU)/cisplatin combination in BTC, we designed a new therapeutic schedule, the LV5FU2-P regimen.

PATIENTS AND METHODS

Twenty-nine patients with advanced or metastatic BTC were prospectively enrolled in the study. The treatment (LV5FU2-P regimen) consisted of a biweekly administration of a 2-h infusion of leucovorin 200 mg/m(2), a 400 mg/m(2) bolus of 5-FU followed by a 22-h continuous infusion of 600 mg/m(2) 5-FU on two consecutive days and cisplatin 50 mg/m(2) on day 2. Clinical symptoms, performance and weight changes were monitored.

RESULTS

Objective responses were observed in 10 patients (34%) (95% confidence interval 23% to 45%) including one complete response and nine partial responses (stabilization 38%, progression 28%). Median progression-free survival and overall survival were 6.5 and 9.5 months, respectively. Weight gain was observed in 45% of patients and performance status improved in 60%. One patient had a grade 4 thrombocytopenia, and grade 3 toxicity occurred in 41% of patients. There were no treatment-related deaths.

CONCLUSIONS

This study, one of the largest phase II trials performed for this disease, shows that the LV5FU2-P regimen is an active and well-tolerated chemotherapy for advanced and metastatic BTC.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Analysis of the relationships between clinicopathologic factors and survival time in intrahepatic cholangiocarcinoma

BACKGROUND

This study elucidated the relationships between various clinicopathologic factors and the outcome of patients with intrahepatic cholangiocarcinoma (ICC) treated by hepatic resection.

METHODS

A total of 37 ICC patients were treated by hepatic resection in our department between March 1979 and March 2001. Eleven clinicopathological variables (age, sex, preoperative jaundice, operative curability, number of tumors, UICC [Union Internationale Contre le Cancer] pT factor, UICC pN factor, UICC pM factor, histological tumor type, 10-year period during which they initially examined, and adjuvant therapy) were selected for univariate and multivariate analysis to evaluate their influence on the outcome.

RESULTS

The actuarial 1-, 3-, and 5-year survival rates in the 37 resected cases were 54.1%, 34.0%, and 23.9%, respectively. The stage of the ICC influenced their overall survival rate. The univariate analysis revealed that curative resection (P = 0.0018), UICC pT factor (P = 0.0445), pN factor (P = 0.0029), pM factor (P = 0.0022), and histological type (P = 0.0030) were significant risk factors for survival. Multivariate analysis revealed that noncurative resection, lymph node metastasis, and less differentiated histological type were significant risk factors for poor outcome. All 6 of the 37 patients who survived more than 5 years had undergone curative resection, all of their tumors were well differentiated, and none had lymph node metastasis.

CONCLUSIONS

Curative surgical resection remains the only effective approach to the treatment of ICC. Extensive resection is not indicated if lymph node metastasis can be identified preoperatively or intraoperatively. Current adjuvant therapy is ineffective, and it will be necessary to assess the efficacy of new adjuvant therapy strategies or the addition of new agents in terms of the outcome of ICC.

Radiofrequency Ablation of Recurrent Cholangiocarcinoma

Intrahepatic recurrence of cholangiocarcinoma after primary resection has traditionally been considered a contraindication to surgical management. Improvements in ablative technologies such as radiofrequency ablation (RFA) offer the surgeon additional alternatives in the management of selected intrahepatic tumors. We present a case report of a single intrahepatic recurrence of cholangiocarcinoma 12 months after primary resection of extrahepatic cholangiocarcinoma including right lobectomy for intrahepatic extension. The patient received operative treatment and RFA of the intrahepatic lesion. RFA successfully ablated the recurrent tumor, and the patient remains free of detectable disease 10 months later. A review of literature is presented. This is the first known report of the use of RFA for intrahepatic cholangiocarcinoma. In selected cases of primary or recurrent cholangiocarcinoma, RFA may increase the percentage of patients considered surgically treatable.

Cholangiocarcinoma of the Hepatic Hilum (Klatskin Tumor)

Since the description by Klatskin in 1965, the management of patients with adenocarcinoma of the hepatic bile duct bifurcation is viewed as a challenging clinical problem with a relatively poor prognosis. Surgery continues to be the mainstay of therapy. Complete resection of the tumor with negative histologic margins offers the best possibility of long-term survival, and hepatic resection is a critical component of the operative approach. Adjuvant chemoradiotherapy has failed to provide a significant survival benefit. Orthotopic liver transplantation for otherwise unresectable lesions remains controversial, as tumor recurrence has been reported in more than 90% of patients. With the shortage of organs, such patients to be selected carefully for transplanation. For patients who present with widespread disease and those with high operative risks, advances in interventional radiology and endoscopy have facilitated nonsurgical management options. Biliary decompression using expandable metallic stents provides superior patency and decreased frequency of hospitalization when compared with plastic stents. Moreover, patients treated with expandable metal stents have survival rates comparable with those who undergo surgical decompression, with fewer early complications. The benefit of external beam radiotherapy for palliation of proximal cholangiocarcinoma is uncertain. Radiotherapy in conjunction with biliary stenting has a survival benefit over stenting alone, but is not without potential toxicity. It should be considered as an adjunct to biliary decompression in all patients with good performance status, because modern conformal CT-based dosimetry can minimize toxicity to normal adjacent tissue. Photodynamic therapy is emerging as a new palliative treatment modality for patients with unresectable tumors in whom stenting has failed. It offers the advantage of an endoscopic delivery system, and unlike radiotherapy, photodynamic therapy may be delivered repeatedly.

Imaging of hepatic transplantation

Hepatic transplantation has become the treatment of choice for advanced irreversible liver disease. More than 4,000 hepatic transplantations were performed in the United States in 1997 and more than 11,000 are awaiting transplantation. Graft endurance and overall patient survival has been steadily improving, and between 1992 and 1994, 82% of the patients who received a liver transplant survived for at least a year. Today, liver transplant patients have a five-year survival rate of approximately 75%. The improvement in survival can be attributed to better patient selection and preparation, advances in organ preservation, improved immunosuppressive therapy agents and refinement of surgical techniques. In this article, we will address the hepatic parenchyma and vascular structures that should be evaluated prior to and following liver transplantation, the range of expected anomalies and abnormalities, and the utility of each of the three main imaging modalities, namely ultrasonography, computed tomography and magnetic resonance imaging in this assessment.

Rapamycin inhibits primary and metastatic tumor growth by antiangiogenesis: involvement of vascular endothelial growth factor

Conventional immunosuppressive drugs have been used effectively to prevent immunologic rejection in organ transplantation. Individuals taking these drugs are at risk, however, for the development and recurrence of cancer. In the present study we show that the new immunosuppressive drug rapamycin (RAPA) may reduce the risk of cancer development while simultaneously providing effective immunosuppression. Experimentally, RAPA inhibited metastatic tumor growth and angiogenesis in in vivo mouse models. In addition, normal immunosuppressive doses of RAPA effectively controlled the growth of established tumors. In contrast, the most widely recognized immunosuppressive drug, cyclosporine, promoted tumor growth. From a mechanistic perspective, RAPA showed antiangiogenic activities linked to a decrease in production of vascular endothelial growth factor (VEGF) and to a markedly inhibited response of vascular endothelial cells to stimulation by VEGF. Thus, the use of RAPA, instead of cyclosporine, may reduce the chance of recurrent or de novo cancer in high-risk transplant patients.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]

PURPOSE

Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma.

PATIENTS AND METHODS

Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases.

RESULTS

Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2.

CONCLUSION

Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

The antineoplastic drug Paclitaxel has immunosuppressive properties that can effectively promote allograft survival in a rat heart transplant model

INTRODUCTION

Recurrent and de novo neoplasms are ominous risk factors for transplant patients. In particular, when organ transplantation is attempted to cure isolated cancers, conventional immunosuppression likely promotes cancer reestablishment. Therefore, drugs with both immunosuppressive and antineoplastic activity are needed. We show that the anticancer agent paclitaxel may fulfill these diverse expectations.

METHODS

Heterotopic heart transplantation was performed in the ACI-to-Lewis or Lewis-to-ACI rat-strain combination and paclitaxel was injected i.p. daily (days 0-14) at doses from 0.75-1.5 mg/kg. Serum cytotoxic antidonor antibody levels were measured using a complement-mediated cell cytotoxicity assay. In vitro, the effect of paclitaxel on Lewis lymphocyte viability and apoptosis was determined. Also, Lewis lymphocytes preconditioned with irradiated ACI cells+/-paclitaxel, were restimulated with ACI cells and tested for cytotoxic T cell (CTL) activity and interleukin-2 (IL-2) production.

RESULTS

Paclitaxel promoted heart allograft survival in a dose-dependent manner in both high- and low-responder transplant combinations. Furthermore, low-doses of paclitaxel (0.75-1.0 mg/kg) and cyclosporine (1 mg/kg) in combination synergistically increased transplant survival. Immunologically, paclitaxel markedly reduced the antidonor cytotoxic antibody response. In vitro, nearly 90% of prestimulated lymphocytes were killed by paclitaxel and cells became positive for the apoptosis marker, annexin-V. Furthermore, paclitaxel reduced CTL activity and IL-2 production after alloantigen rechallenge.

CONCLUSION

Paclitaxel, a clinically proven antineoplastic agent, also has potent immunosuppressive properties in rodent organ transplantation. This drug could be extremely valuable in transplant situations where de novo cancer develops, or when organ transplantation is performed to treat isolated, but typically recurrent, neoplasms.

Intrahepatic cholangiocarcinoma: its mode of spreading and therapeutic modalities

Intrahepatic cholangiocarcinoma (IHCC) is a primary adenocarcinoma of the liver, arising from the intrahepatic bile ducts. The prognosis is generally poor because locoregional extension is usually advanced at the time of diagnosis. Even after a resection, the outcome for patients with advanced IHCC is extremely poor, and the presence of lymph node metastasis has been reported in most previous studies to be the worst prognostic factor after a resection. There are no clear guidelines on lymph node dissection with IHCC. In this article, we review the mode of invasion and the therapeutic modalities: hepatic resection, lymph node dissection, liver transplantation, radiation, and chemotherapy for IHCC.

Liver transplantation for cholangiocellular carcinoma: analysis of a single-center experience and review of the literature

Cholangiocellular carcinoma (CCC) is a biliary malignancy that frequently presents in advanced unresectable stages. The role of liver transplantation (LT) as a surgical modality is unclear. The goal of this study is to evaluate outcomes of patients with CCC undergoing LT. A retrospective analysis of all patients undergoing LT was undertaken. Only those patients with the pathological diagnosis of CCC were included on the study. Patients were divided into two groups based on primary tumor location: extrahepatic (EH)-CCC and intrahepatic (IH)-CCC. The Kaplan-Meier method was used to calculate overall and recurrence-free survival. Log-rank analysis was used to determine the significance of prognostic variables. Twenty-five patients were identified: 9 patients with EH-CCC (5 patients, Klatskin-type; 2 patients, the middle third; and 2 patients, the distal third) and 16 patients with IH-CCC. Mean age was 47.1 +/- 10.6 years. There were 14 men and 11 women. Tumor stage was local (stages I and II; n = 9) or advanced (stages III and IV; n = 16). Overall and disease-free survival rates were 71% and 67% at 1 year and 35% and 32% at 3 years, respectively. Analysis of variables showed statistically significant improved outcomes (P < .05) for the absence of contiguous organ invasion at LT, small tumor size, and single tumor foci. This study indicates that early survival after LT for CCC is acceptable. Three-year disease-free survival is achieved in approximately 30% of patients. These outcomes can be improved by applying strict selection criteria based on prognostic variables identified in this study.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Biliary tract cancer

Advances in cellular and molecular biology of extrahepatic cholangiocarcinoma and gallbladder adenocarcinoma are providing innovative means for the diagnosis and treatment of biliary tract cancer. Similarly, refinements in noninvasive studies--including helical computed tomography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography--are enabling more accurate diagnosis, staging, and treatment planning for these tumors. Complete resection remains the only means for cure, and recent reports from major hepatobiliary centers support aggressive wide resection for bile duct and gallbladder cancer. Palliation of malignant strictures has improved with advanced endoscopic techniques, newer polyurethane-covered stents, endoscopic microwave coagulation therapy, and radiofrequency intraluminal endohyperthermia. The preliminary data on such minimally invasive techniques suggest an improvement in quality of life and survival for selected patients.

Liver transplantation: current status and novel approaches to liver replacement

The major challenge currently facing liver transplantation is the performance of a greater number of liver transplants, which has been fueled by the large and growing disparity between the increasing number of qualified patients listed for transplantation and the relatively static number of available cadaver donor organs. In the past 2 years, approximately 4500 liver transplants have been performed annually, with 1-year survival rates in the 85%-90% range, while the waiting list has expanded as of November 2000 to more than 16,000 patients, resulting in an increasing death rate among listed patients. In the short term, there will continue to be a major focus on more effective use of available cadaver donor organs to balance the competing principles of justice (patients with most urgent need for transplant and lower probability of posttransplant survival) and medical utility (patients with less urgent need for transplant and higher odds of postoperative survival). Over the long term, there will be an increasing application of novel approaches to liver replacement including cadaver split liver transplantation and adult living donor liver transplantation and possibly, in the more distant future, xenotransplantation and hepatocyte transplantation. The treatment, and ideally the prevention, of recurrent disease after liver transplantation, particularly chronic hepatitis C-the most common indication for transplantation-is a major priority to optimize the use of liver grafts. Finally, improved immunosuppressive strategies, including movement toward minimal immunosuppression and steroid withdrawal and the development of safer and more effective drugs, is another important factor that has the potential to increase the success of liver transplantation.