The development and extension of hepatohilar bile duct carcinoma. A three-dimensional tumor mapping in the intrahepatic biliary tree visualized with the aid of a graphics computer system

A comprehensive study and extensive review of the Caudate lobe: The last piece of "Jigsaw" puzzle

Many liver surgeons have updated their understanding of the liver in recent years because of detailed studies on the liver anatomy and the rapid advances in laparoscopic liver surgery. Despite newer approaches, concepts and methods, research on the caudate lobe continues to be based on case reports and several persistent challenges concerning caudate lobe surgery that are worth discussing. Based on the literature and the author's experience, this study considers and addresses the challenges associated with caudate lobectomy encountered by most liver surgeons. We searched PubMed for relevant articles in English for 'caudate lobe', 'cholangiocellular carcinoma', 'laparoscopic caudate resection', 'right-side boundary of the caudate lobe' and 'assessment of hepatic functional reserve' published up to May 2022. This study reviewed the anatomical history of the caudate lobe, focusing on the challenges associated with caudate lobe-related surgical resection. Due to the unique anatomical position of the caudate lobe, surgical strategy for caudate lobe resection is particularly important, and the technical requirements for hepatobiliary surgeons are also extremely strict. Therefore, understanding the anatomical history of the caudate lobe and discussing the challenges associated with caudate lobectomy is essential.

Achieving precision surgery in laparoscopic liver resection with the aid of preoperative three-dimensional reconstruction: A case report

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Laparoscopic liver surgery is evolving and its spread is now starting to take place.

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Three-dimensional reconstruction imaging still remains a scarcely used technique.

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Considering the difficulty of liver resection surgery, a precise knowledge of the patient’s anatomy is essential in the preoperative planning of the intervention. Three-dimensional reconstruction imaging provides useful information in addition to conventional imaging, allowing a more accurate preoperative planning, and being used as a navigation instrument during liver resection.

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The use of three-dimensional reconstruction imaging allows to predict the precise location and direction of anatomical structures with high approximation, allowing to reach a high degree of precision surgery.

Introduction

The use of three-dimensional image reconstruction in liver surgery is well-known and has got many applications: It was first developed for vein reconstruction in liver transplantation and for liver volumetry to prevent post hepatectomy liver failure (PHLF) after major resections. There are many other advantages described in the literature provided by three-dimensional reconstruction, however its diffusion is currently limited.

Clinical case

We present the case of a woman with a single colon cancer metastasis in segment 5 of the liver. Using CT scan images we created a three dimensional reconstruction of the patient’s liver and its inners structures. The rendering was used to hypothesize the plan of dissection and to predict the pedicles that needed to be dissected during the procedure.

Discussion

We try to demonstrate that, thanks to three dimensional image reconstruction, all the structures that need to be dissected could be effectively located prior to the the surgery with a high grade of approximation. Furthermore the 3D reconstruction could be used as a step by step guide during the whole surgical procedure, showing all the pedicles To be encountered and dissected at every stage.

Conclusion

3d reconstruction of the liver is a valid aid in the interpretation of preoperative imaging and intraoperative ultrasound, both for the surgeon and for the entire equipe, facilitating comprehension of patient’s liver anatomical features. It allows to predict the location and direction of the pedicles that need to be dissected and resected with high approximation, in order to achieve a more precise and tailored surgery.

Significance of proximal ductal margin status after resection of hilar cholangiocarcinoma

BACKGROUND

The impact of additional resection for positive proximal bile duct margins during hepatic resection of hilar cholangiocarcinoma (HCCA) on survival and disease progression remains unclear. We asked how re-resection of positive proximal bile duct margins affected outcomes.

METHODS

Patients undergoing resection between 1993-2017 were reviewed. Both frozen section and final margin status were reviewed. Overall survival was the primary outcome.

RESULTS

153 patients underwent surgical resection for HCCA. Median survival (months) for initial margin negative (M-), margin-positive to margin-negative (M+/M-) and margin-positive to margin-positive (M+/M+) was 45, 33, and 35 months respectively. Nodal metastases increased with margin positivity: 32% with M-, 49% with M+/M- and 63% with M+/M+ (p = 0.016). Local/regional progression more frequently occurred in M+/M- (27.3%) and M+/M+ (33.3%) patients (M+/M- vs. M-: p = 0.41, M+/M+ vs. M-: p = 0.27). Patients receiving postoperative chemotherapy were 33% M-, 46% M+/M- and 63% in M+/M+. Postoperative radiation was used in 13% of M-, 31% of M+/M- and 63% of M+/M+. Most frequent initial recurrences were within the liver and hepaticojejunostomy site.

CONCLUSION

Competing risk for systemic disease based on primary characteristics of HCCA outweighs the impact of re-resection to achieve R0 status. Improved survival will likely depend on future regional and systemic therapy.

A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma

BACKGROUND

Surgical resection remains the only potentially curative therapy for hilar cholangiocarcinoma (CCC) patients. This meta-analysis aimed to review the current evidence on perioperative and long-term outcomes of routine caudate lobe resection (CLR) for surgical treatment of hilar CCC.

METHODS

A systematic literature search using MEDLINE, EMBASE and Cochrane databases was performed for studies providing comparative data on perioperative and long-term outcomes of patients undergoing resection for hilar CCC with and without CLR. The MINORS score was used for quality assessment. For time-to-event outcomes hazard ratios (HRs) and associated 95% CI were extracted from identified studies, whereas risk ratios (RRs) were calculated for overall morbidity, mortality, and resection margin status. Meta-analyses were carried out using random-effects models.

RESULTS

Eight studies involving 1350 patients met the inclusion criteria. The quality of the included studies was low to moderate. CLR resulted in significantly improved overall survival (HR 0.49; 95%CI 0.32-0.75, P < 0.01). Postoperative morbidity (RR 0.93; 95% CI 0.77-1.13; P = 0.48) and mortality (RR 1.01; 95% CI 0.42-2.41; P = 0.99) rates were comparable between both groups. Patients without concomitant CLR were at higher risk for residual tumor at the resection margin (RR 1.40; 95% CI 1.09-1.80; P = 0.01).

CONCLUSION

CLR is associated with improved long-term survival and negative tumor margins after resection of hilar CCC with no adverse impact on perioperative outcomes. CLR might provide the potential to become a standard-of-care procedure in the surgical management of hilar CCC.

Histological features of precancerous and early cancerous lesions of biliary tract carcinoma

Biliary tract carcinoma develops within the intrahepatic or extrahepatic biliary tree and gallbladder. Primary sclerosing cholangitis, hepatolithiasis, congenital choledochal cyst, liver fluke infection, pancreatobiliary maljunction, toxic exposures and hepatitis virus infection are risk factors for the development of human biliary carcinoma. The precise molecular abnormalities of biliary carcinogenesis are still unknown, but chronic inflammatory conditions induce the production of reactive oxygen or nitrogen species leading to DNA damage. Recent studies indicate that cholangiocarcinoma of the large bile duct may arise in premalignant lesions such as biliary intraepithelial neoplasm (BilIN) and intraductal papillary neoplasm of the bile duct (IPNB). BilIN and IPNB are generally confined to the large and septal-sized bile duct. BilINs are occasionally observed in non-biliary liver cirrhosis as well as chronic biliary disease. In contrast, the precursor lesion of intrahepatic cholangiocarcinoma of the small bile duct type remains unclear. We herein demonstrated the histological characteristics of different tumor development pathways from premalignant lesion to carcinoma in different sites of the biliary tree.

Hepatopancreatoduodenectomy for anastomotic recurrence from residual cholangiocarcinoma: report of a case

Resection of cholangiocarcinoma often results in a positive ductal margin, from carcinoma in situ (CIS) near the main tumor; however, the biological behavior of the residual CIS after surgical resection remains equivocal. We report a case of late local recurrence of CIS, defined as long-term tumor progression from CIS residue at the ductal stump. The patient, a 73-year-old man, had undergone bile duct resection for distal cholangiocarcinoma, leaving positive ductal margins with CIS. A biliary stricture was found 10 years later at the site of anastomosis, and right hepatectomy with pancreatoduodenectomy was performed. Based on histological analogy and the evidence of remnant CIS, a final diagnosis of late local recurrence from the CIS foci was made. This uncommon mode of recurrence should be considered in patients with early-stage disease with expected favorable survival because salvage surgery is feasible for selected patients.

Role of caudate lobectomy in type III A and III B hilar cholangiocarcinoma: a 15-year experience in a tertiary institution

BACKGROUND

Concomitant liver resection for type III hilar cholangiocarcinoma could improve the R0 resection rate and long-term outcome. In the present study, we examine the specific role of caudate lobectomy in liver resection for type III(A) and III(B) hilar cholangiocarcinoma and the prognostic factors for survival in this group of patients.

METHODS

We reviewed all patients with type III(A) and III(B) hilar cholangiocarcinoma who underwent liver resection in Samsung Medical Center from January 1995 to July 2010. Patients were divided into those with and without caudate lobectomy (CL). The log rank test and Cox regression analysis were employed to investigate for prognostic factors of survival.

RESULTS

There were 127 patients in this cohort, 57 without CL (44.9%) and 70 with CL (55.1%). The demographics and symptoms of presentation were comparable. The median preoperative bilirubin level was significantly higher in the group undergoing CL (p = 0.017). Patients with CL had a significantly better overall survival (OS) (CL: 64.0 months vs without CL: 34.6 months) (p = 0.010) and disease-free survival (DFS) (CL: 40.5 months vs without CL: 27.0 months) (p = 0.031). Multivariate analysis showed that presence of symptoms (p = 0.025) and positive lymph node (LN) metastasis (p < 0.001) were negative prognostic factors for OS. Furthermore, multivariate analysis for DFS found that caudate lobectomy (p = 0.016) and positive LN metastasis (p = 0.001) were positive and negative prognostic factors, respectively.

CONCLUSIONS

Caudate lobectomy contributed to improvement of DFS and OS in type III hilar cholangiocarcinoma. Other prognostic factors include positive LN metastasis and presence of symptoms.

Surgical outcomes of multicentric adenocarcinomas of the biliary tract

OBJECTIVE

In comparison to single biliary cancers, distinct features of biliary multicentric adenocarcinomas are not yet clear.

METHODS

From July 1992 to July 2009, 393 patients underwent surgery for cancers of the biliary tract at the National Cancer Center Hospital East, Kashiwa, Japan. Clinicopathological characteristics and surgical outcomes of multicentric biliary adenocarcinoma were compared with those of single cancers.

RESULTS

During the period, 10 cases (2.5%) with multicentric cancer (6 synchronous and 4 metachronous cancers) were found among 393 cases of biliary cancer. Pathologically, compared with single cancers, multicentric adenocarcinomas were more likely to be early cancers and to be papillary carcinomas with both superficial epithelial tumor spread and extensive dysplastic epithelium, but were less likely to have lymph node metastases (P < 0.01). The proportion of multicentric cancers among early papillary cancers was high (9/24, 37.5%). Clinically, no recurrences were detected in lymph nodes, peritoneum or distant organs, but one recurrence in the remnant bile duct. Only one patient died from cancer progression. The overall survival of patients with multicentric adenocarcinomas was statistically the same as that of single cancers (median survival: 69 vs. 30 months, P = 0.47).

CONCLUSIONS

Multicentric adenocarcinomas of the biliary tract have distinct features compared with single cancers.

Contrast-enhanced ultrasound in diagnosis and characterization of focal hepatic lesions

The extensive use of imaging techniques in differential diagnosis of abdominal conditions and screening of hepatocellular carcinoma in patients with chronic hepatic diseases, has led to an important increase in identification of focal liver lesions. The development of contrast-enhanced ultrasound (CEUS) opens a new window in the diagnosis and follow-up of these lesions. This technique offers obvious advantages over the computed tomography and magnetic resonance, without a decrease in its sensitivity and specificity. The new second generation contrast agents, due to their intravascular distribution, allow a continuous evaluation of the enhancement pattern, which is crucial in characterization of liver lesions. The dual blood supply in the liver shows three different phases, namely arterial, portal and late phases. The enhancement during portal and late phases can give important information about the lesion’s behavior. Each liver lesion has a different enhancement pattern that makes possible an accurate approach to their diagnosis. The role of emerging techniques as a contrast-enhanced three-dimensional US is also discussed. In this article, the advantages, indications and technique employed during CEUS and the different enhancement patterns of most benign and malignant focal liver lesions are discussed.

CpG island hypermethylation and repetitive DNA hypomethylation in premalignant lesion of extrahepatic cholangiocarcinoma

Biliary intraepithelial neoplasia (BilIN) is the premalignant lesion of extrahepatic cholangiocarcinoma (EHC), and there are no published data regarding epigenetic changes throughout disease progression from normal biliary epithelia to BilIN to EHC. The objective of this study was to identify the occurrence of CpG island hypermethylation and repetitive DNA hypomethylation in BilIN. A total of 50 EHCs, 31 BilINs, and 31 normal cystic duct samples were analyzed for their methylation status in seven genes and two repetitive DNA elements. The number of methylated genes increased with disease progression (normal bile duct, 0.6; BilIN, 2.0; EHC, 3.6; P < 0.001). The methylation level of examined genes was significantly higher in BilIN than in normal samples (TMEFF2, HOXA1, NEUROG1, and RUNX3, P < 0.05) and in EHC than in BilIN samples (TMEFF2, HOXA1, NEUROG1, RUNX3, RASSF1A, and APC, P < 0.05). Long interspersed nucleotide element-1 (LINE-1) and juxtacentromeric satellite 2 (SAT2) methylation levels were markedly lower in EHC than in normal duct and BilIN samples, and BilIN samples showed a decrease of SAT2 methylation levels but no decrease of LINE-1 methylation levels compared to normal samples. These findings suggest that most of cancer-specific CpG island hypermethylation occur in the stage of BilIN and that CpG island hypermethylation seems to occur earlier than repetitive DNA element hypomethylation.

Characteristics of common solid liver lesions and recommendations for diagnostic workup

Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.

Extrahepatic bile duct carcinoma with extensive intraepithelial spread: a clinicopathological study of 21 cases

Extrahepatic bile duct carcinoma occasionally presents with intraepithelial spread for a considerable area around the main tumor. In this study, we compared clinicopathological features of extrahepatic bile duct carcinoma with and without extensive intraepithelial spread (>or=20 mm from the main tumor). Out of 117 cases of extrahepatic bile duct carcinoma, 21 (18%) were found to have extensive intraepithelial spread. Those cases were pathologically characterized by a papillary or nodular main tumor, a more differentiated histological grade, less deep invasion, and infrequent portal vein or hepatic invasion in comparison with cases without intraepithelial spread. Areas of intraepithelial spread histologically consisted of low-papillary growth (17 cases, 81%) and completely flat growth (4 cases, 19%) of carcinoma cells. The former histology corresponded to a macroscopic granular mucosa, whereas the latter growth was hardly detected by gross examination. Immunohistochemically, in 16 of 21 cases (76%), at least one of p53, CEA, and MUC1 was expressed in both the main tumor and the spreading area. Interestingly, patients with intraepithelial spread had a better postoperative prognosis than those without intraepithelial spread (P=0.009). However, three patients had anastomotic recurrence 54-130 months after surgery. In conclusion, intraepithelial-spreading bile duct carcinoma is characterized by papillary or nodular main lesions, a more differentiated histological grade, and less invasiveness. The presence of intraepithelial spread was not an indicator of a poor prognosis, but carcinoma in situ at the bile duct stump could cause late anastomotic recurrence after surgery.

Local surgical resection of hilar cholangiocarcinoma: is there still a place?

In recent decades, surgical treatment of hilar cholangiocarcinoma has moved toward liver surgery in association with biliary resection in order to increase radicality and to achieve better survival. Results of local resection compared with hepatectomy associated with bile duct resection and its actual indications have to be clarified. A systematic review of relevant studies published before December 2007 was performed. Original published studies comparing the results of isolated local excision with those of hepatectomy associated with bile duct resection were identified and the reported results were synthesized. The pathologic data suggest that isolated bile duct resection cannot be adequate: required wide surgical margins; neoplastic extension along perineural sheaths; Segment 1 neoplastic invasion. Considering postoperative outcomes, in the 1990s, local resection had significantly lower mortality rates than liver resection. In recent years, the short-term results of liver surgery have improved significantly, while mortality rates have decreased. The R0 resection rate is significantly higher after associated liver resection. Comparison of survival results between local resection and associated liver surgery is difficult because, in the majority of series, the treatment was planned according to tumor extension. Better long-term outcomes have been reported after liver resection than after isolated bile duct resection, even for Bismuth-Corlette type I-II cholangiocarcinoma. Long-term survivors after local resection have been reported in a few selected patients with Bismuth-Corlette type I Tis-T1 or papillary neoplasm.

Long-term, tumor-free survival after radiotherapy combining hepatectomy-Whipple en bloc and orthotopic liver transplantation for early-stage hilar cholangiocarcinoma

This retrospective study reviews our experience in surveillance and early detection of cholangiocarcinoma (CC) and in using en bloc total hepatectomy-pancreaticoduodenectomy-orthotopic liver transplantation (OLT-Whipple) to achieve complete eradication of early-stage CC complicating primary sclerosing cholangitis (PSC). Asymptomatic PSC patients underwent surveillance using endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) with multilevel brushings for cytological evaluation. Patients diagnosed with CC were treated with combined extra-beam radiotherapy, lesion-focused brachytherapy, and OLT-Whipple. Between 1988 and 2001, 42 of 119 PSC patients were followed according to the surveillance protocol. CC was detected in 8 patients, 6 of whom underwent OLT-Whipple. Of those 6 patients, 4 had stage I CC, and 2 had stage II CC. All 6 OLT-Whipple patients received combined external-beam and brachytherapy radiotherapy. The median time from diagnosis to OLT-Whipple was 144 days. One patient died 55 months post-transplant of an unrelated cause, without tumor recurrence. The other 5 are well without recurrence at 5.7, 7.0, 8.7, 8.8, and 10.1 years. In conclusion, for patients with PSC, ERCP surveillance cytology and intralumenal endoscopic ultrasound examination allow for early detection of CC. Broad and lesion-focused radiotherapy combined with OLT-Whipple to remove the biliary epithelium en bloc offers promising long-term, tumor-free survival. All patients tolerated this extensive surgery well with good quality of life following surgery and recovery. These findings support consideration of the complete excision of an intact biliary tree via OLT-Whipple in patients with early-stage hilar CC complicating PSC.

Proposal of progression model for intrahepatic cholangiocarcinoma: clinicopathologic differences between hilar type and peripheral type

It is important to clarify the histologic progression of intrahepatic cholangiocarcinoma (ICC) in consideration of its origin from the intrahepatic large or small biliary ducts. On the basis of the gross and histologic assessment, we classified 87 cases of ICC smaller than 5 cm in diameter into hilar type (H-ICC, n=38) or peripheral type (P-ICC, n=49) to compare their clinical and histologic features. Biliary dysplasia was observed in 65.8% (25/38) of H-ICC cases, whereas hepatitis virus infection and liver cirrhosis were associated with 46.7% (21/45) and 28.6% (14/49) of P-ICC, respectively. The frequency of perineural invasion, lymph node metastasis, and extrahepatic recurrence of H-ICC was significantly higher than that of P-ICC (P<0.0001, 0.0106, and 0.0279, respectively). H-ICC cases showed frequent vascular invasion and intrahepatic metastasis even with small tumor size, compared with P-ICC cases. H-ICC showed large duct involvement within the tumor, and in the cases of large tumor size, intraductal spread was detected in the tumor periphery. P-ICC of small size contained preserved architecture of the portal tracts. The survival of patients with H-ICC was worse than that of patients with P-ICC (P=0.0121). The independent and best prognostic factor by multivariate analysis was intrahepatic metastasis for H-ICC and lymph node metastasis for P-ICC. Our results suggest that ICCs derived from a different level of biliary ducts were related to different premalignant conditions and different tumor progression. Some ICCs arising from the large biliary duct are likely to exhibit an aggressive course even in cases of small tumor size. The recognition of the above events induces the proper therapy.

Measurement of the invasion depth of extrahepatic bile duct carcinoma: An alternative method overcoming the current T classification problems of the AJCC staging system

Tumor staging of extrahepatic bile duct (EBD) carcinoma is problematic for a number of reasons, including definitional problems with the current T classification of the American Joint Committee on Cancer staging system and the common occurrence of severe desmoplastic stromal reaction around the advancing edges of these tumors. To address these problems we evaluated the depth of invasion in 222 cases of EBD carcinoma by measuring the distance between the basal lamina of the adjacent normal epithelium to the most deeply infiltrating tumor cells, and compared this evaluation to time of survival and other clinical and pathologic parameters. A complex pattern of survival time versus the depth of invasion was observed by censored local regression. The recursive-partitioning technique was coupled with the log-rank test to identify 2 significant cutoff points for the depth of invasion, 5 and 12 mm, which segregated patients into 3 groups with statistically significant decreasing length of median survival (<5 mm, 61 mo; 5 to 12 mm, 23 mo; >12 mm, 17 mo, P < 0.001). On the basis of the present data, we propose that a measurement of the depth of invasion should be performed in cases of EBD carcinoma, and that the T classification of EBD carcinoma should be changed to incorporate this measurement: T1 (<5 mm), T2 (5 to 12 mm), and T3 (>12 mm).

Extended right hemihepatectomy as a salvage operation for recurrent bile duct cancer 3 years after pancreatoduodenectomy

Salvage surgery for recurrent bile duct cancer is generally impractical due to local invasion of surrounding major vascular structures or distant metastases. We describe a case of a relapsed tumor in the right hepatic duct 3 years after pancreatoduodenectomy for middle to distal bile duct cancer. The recurrent tumor, measuring 25 x 12 x 12 mm, was mostly confined within the right hepatic duct. It displayed an intraductal superficial extension rather than transmural invasive growth to the hepatic hilum. An extended right hemihepatectomy was successfully performed with a histologically negative margin. The patient is currently doing well without any signs of local recurrence or distant metastasis 8 months after the second operation. Precise pathological examination revealed that the lesion had originated from multicentric foci in the right hepatic duct, not as a result of anastomotic recurrence. These results raised the consideration of a potentially more indolent subgroup of bile duct cancer. This is a detailed report of a successfully resected recurrent bile duct cancer, for which the patient underwent major hepatectomy as a salvage procedure after pancreatoduodenectomy for the primary tumor. An aggressive surgical approach will be a rational treatment of choice for recurrent disease when metachronous multicentric tumor development in the bile duct is suspected and curative resection can be safely performed.

Thermo-chemo-radiotherapy for advanced bile duct carcinoma

AIM: Complete resection of the bile duct carcinoma is sometimes difficult by subepithelial spread in the duct wall or direct invasion of adjacent blood vessels. Nonresected extrahepatic bile duct carcinoma has a dismal prognosis, with a life expectancy of about 6 mo to 1 year. To improve the treatment results of locally advanced bile duct carcinoma, we have been conducting a clinical trial using regional hyperthermia in combination with chemoradiation therapy.

METHODS: Eight patients complaining of obstructive jaundice with advanced extrahepatic bile duct underwent thermo-chemo-radiotherapy (TCRT). All tumors were located in the upper bile duct and involved hepatic bifurcation, and obstructed the bile duct completely. Radiofrequency capacitive hyperthermia was administered simultaneously with chemotherapeutic agents once weekly immediately following radiotherapy at 2 Gy. We administered heat to the patient for 40 min after the tumor temperature had risen to 42°C. The chemothe-rapeutic agents employed were cis-platinum (CDDP, 50 mg/m²) in combination with 5-fluorouracil (5-FU, 800 mg/m²) or methotrexate (MTX, 30 mg/m²) in combination with 5-FU (800 mg/m²). Number of heat treatments ranged from 2 to 8 sessions. The bile duct at autopsy was histologically examined in three patients treated with TCRT.

RESULTS: In respect to resolution of the bile duct, there were three complete regression (CR), two partial regression (PR), and three no change (NC). Mean survival was 13.2 ± 10.8 mo (mean±SD). Four patients survived for more than 20 mo. Percutaneous transhepatic biliary drainage (PTBD) tube could be removed in placement of self-expandable metallic stent into the patency-restored bile duct after TCRT. No major side effects occurred. At autopsy, marked hyalinization or fibrosis with necrosis replaced extensively bile duct tumor and wall, in which suppressed cohesiveness of carcinoma cells and degenerative cells were sparsely observed.

CONCLUSION: Although the number of cases is rather small, TCRT in the treatment of locally advanced bile duct carcinoma is promising in raising local control and thus, long-term survival.

Perinidal dilated capillary networks in cerebral arteriovenous malformations

OBJECTIVE

The perinidal vascular structures of cerebral arteriovenous malformations were examined, to clarify their pathomorphological features.

METHODS

Twenty-two resected specimens of human brain structures adjacent to the nidus were examined. The vessels surrounding the nidus were three-dimensionally reconstructed with a computer graphics system.

RESULTS

In all cases, the analysis of serial sections revealed that perinidal dilated capillaries were located in brain tissue 1 to 7 mm from the nidal border. The vessels surrounding the nidus demonstrated markedly dilated capillary networks (perinidal dilated capillary network [PDCN]). The diameters of the vessels forming the PDCN were 10 to 25 times those of normal capillaries. The PDCN connected not only to the nidus, feeding arteries, and draining veins, via arterioles and venules, but also to the normal capillary network, arterioles, and venules.

CONCLUSION

Without exception, each nidus was accompanied by a PDCN, which connected not only to the nidus, feeding arteries, and draining veins, via arterioles and venules, but also to normal capillaries, arterioles, and venules. The PDCN should be considered in studies aimed at gaining an understanding of the mechanisms underlying the intraoperative and postoperative bleeding, growth, and recurrence of surgically treated cerebral arteriovenous malformations.

Expression of Bcl-2 and Bax in extrahepatic biliary tract carcinoma and dysplasia

AIM: To compare the difference of expression of Bcl-2 and Bax in extrahepatic biliary tract carcinoma and dysplasia, and to analyze the role of Bcl-2 and Bax proteins in the progression from dysplasia to carcinoma and to evaluate the correlation of Bcl-2/Bax protein expression with the biological behaviors.

METHODS: Expressions of Bcl-2 and Bax were examined immunohistochemically in 27 cases of extrahepatic biliary tract carcinomas (bile duct carcinoma: n = 21, carcinoma of ampulla of Vater: n = 6), and 10 cases of atypical dysplasia. Five cases of normal biliary epithelial tissues were used as controls. A semiquantitative scoring system was used to assess the Bcl-2 and Bax reactivity.

RESULTS: The expression of Bcl-2 was observed in 10 out of 27 (37.0%) invasive carcinomas, 1 out of 10 dysplasias, none out of 5 normal epithelial tissues. Bax expression rate was 74.1% (20/27) in invasive carcinoma, 30% (3/10) in dysplasia, and 40% (2/5) in normal biliary epithelium. Bcl-2 and Bax activities were more intense in carcinoma than in dysplasia, with no significant difference in Bcl-2 expression (P = 0.110), and significant difference in Bax expression (P = 0.038). Level of Bax expression was higher in invasive carcinoma than in dysplasia and normal tissue (P = 0.012). Bcl-2 expression was correlated to Bax expression (P = 0.0059). However, Bcl-2/Bax expression had no correlation with histological subtype, grade of differentiation, or level of invasion.

CONCLUSION: Increased Bcl-2/Bax expression from dysplasia to invasive tumors supports the view that this is the usual route for the development of extrahepatic biliary tract carcinoma. Bcl-2/Bax may be involved, at least in part, in the apoptotic activity in extrahepatic biliary carcinoma.

Prognostic value of serum MUC5AC mucin in patients with cholangiocarcinoma

BACKGROUND

The authors recently showed that MUC5AC mucin, which is expressed aberrantly in tumor tissue, is present in significant concentrations in serum from patients with cholangiocarcinoma. Subsequently, determination of serum MUC5AC had high sensitivity and specificity for cholangiocarcinoma. In this study, the possible association between serum MUC5AC mucin and the clinical findings of the patients and their prognostic value were explored.

METHODS

The expression of MUC5AC mucin in serum samples from 179 patients with histologically confirmed cholangiocarcinoma were determined using immunoblotting.

RESULTS

Detection of serum MUC5AC was associated with patients with blood group Type A, larger-sized tumors (> 5 cm), and advanced-stage disease. Patients who had positive serum MUC5AC status had a significantly poorer prognosis (median survival, 127 days; 95% confidence interval [95% CI], 107-180 days) compared with patients who had negative serum MUC5AC status (median survival, 329 days; 95% CI, 199-458 days; P < 0.001). Multivariate analysis with adjustment for all covariates showed that patients who had positive serum MUC5AC status had a 2.5-fold higher risk of death compared with patients who had negative serum MUC5AC status (P < 0.001).

CONCLUSIONS

Serum MUC5AC was associated with tumor burden. The determination of serum MUC5AC may be predictive of poor patient outcome and may be useful in selecting possible treatment options for patients with cholangiocarcinoma. Cancer 2003;98:1438-43.

Papillary carcinoma of the extrahepatic bile duct: characteristic features and implications in surgical treatment

BACKGROUND

Papillary carcinoma of the extrahepatic bile duct presents clinically and histologically distinct features relevant to surgical decision-making.

STUDY DESIGN

Serial sections of 15 specimens of resected papillary carcinoma of the bile duct were histologically examined to determine mode of spread, possibility of multicentric tumor origins, and coincidence with other neoplastic lesions. The presence of anomalous pancreaticobiliary ductal union was also investigated. These characteristics were considered with regard to surgical treatment.

RESULTS

Three patients displaying pancreaticobiliary maljunction and one of three patients with a long common channel (> or = 8 mm) exhibited multicentric tumors. Eight patients (53%) demonstrated superficial spread along a mean length of 37.8 mm (range, 5 to 67 mm) of bile duct mucosa. Multicentric tumors developed synchronously in 4 patients, while metachronous tumors were identified in three patients displaying tumor histology similar to the primary lesions. Two of these three underwent successful repeated resection. Concomitant neoplastic lesions in the biliary tract were identified as mucosal dysplasia in four patients and cholangiocellular carcinoma of the liver in two. All tumors but one were removed via hepatic lobectomy or pancreatoduodenectomy, or both, resulting in a 5-year survival rate of 60%.

CONCLUSIONS

Aggressive resection offers clear survival benefits for patients presenting with tumors displaying extensive superficial spread or multicentric origins. Closer attention should be paid to long common channels in relation to carcinogenesis of the bile duct, in addition to pancreaticobiliary maljunction. The risk of secondary tumor development remains, particularly in patients with pancreaticobiliary maljunction even after excision of the tumor-bearing extrahepatic bile duct.

Pathological appraisal of lines of resection for bile duct carcinoma

BACKGROUND

The aim of this study was to determine the most appropriate line of resection for extrahepatic bile duct carcinoma.

METHODS

A retrospective review was carried out of 253 resected specimens of extrahepatic bile duct carcinoma. Carcinomas were classified histologically as invasive or non-invasive in addition to assessment of the resection margin.

RESULTS

Tumour was present microscopically at the resection margin in 80 (31.6 per cent) of 253 cases, with 46 showing marginal involvement by non-invasive carcinoma, 20 showing invasive carcinoma at a margin, and 14 showing both. Involvement of the resection margin by invasive carcinoma was encountered only when the margin was shorter than 10 mm, whereas non-invasive carcinoma was encountered even when the margin length reached 40 mm. The observed length of microscopic extension of invasive carcinoma beyond the macroscopically evident tumour mass was limited to 10.0 mm. Median microscopic extension of non-invasive carcinoma beyond the mass was 10 mm (75th percentile 19.5 and 14.5 mm in proximal and distal directions respectively; maximum 52 mm). Margins of 20 mm could be assured to be negative proximally in 89.0 per cent of cases and distally in 93.8 per cent.

CONCLUSION

For eradication of invasive extrahepatic bile duct carcinoma, a 10-mm margin is required. However, additional removal of any non-invasive component requires a 20-mm margin. These guidelines should be followed in any operation performed with curative intent.

Specific and effective targeting cancer immunotherapy with a combination of three bispecific antibodies

For the purpose of establishing a new adoptive immunotherapy for bile duct carcinoma (BDC), we previously constructed two kinds of bispecific antibodies (bsAbs), anti-MUC1 x anti-CD3 (M x 3) and anti-MUC1 x anti-CD28 (M x 28), which activate T cells and form bridges between them and MUC1-expressing tumor cells. In our previous studies [Cancer Res. 56 (1996) 4205] specific targeting therapy (STT) consisting of i.v. administration of lymphokine activated killer cells with a T cell phenotype (T-LAK) sensitized with two kinds of bsAbs to human BDC-grafted severe combined immunodeficient (SCID) mice demonstrated remarkable inhibition of tumor growth. However, complete cures could not be obtained. In order to improve antitumor efficacy, we have paid attention to anti-CD2 monoclonal antibodies (mAbs), thought to play an important roles in signal transduction in T cell activation or control of T cell receptor (TCR)-driven activation. Therefore, we developed another bsAb, anti-MUC1 x anti-CD2 (M x 2), in order to examine if this would show synergism with the two previously described bsAbs. The combination of the three bsAbs (M x 3, M x 28 and M x 2 bsAbs) showed highest cytotoxicity against MUC1-expressing BDC cells when given simultaneously with peripheral blood mononuclear cells (PBMCs) or T-LAK cells in vitro. When 2 x 10(7) T-LAK cells sensitized with different combinations of bsAbs were administered four times i.v. to BDC-grafted SCID mice, the best therapeutic result was obtained with a combination of all three bsAbs. These results indicate usefulness of combination of three bsAbs for targeting cancer immunotherapy.

Metaplastic lesions of the extrahepatic bile ducts: a morphologic and immunohistochemical study

Although metaplastic changes can occur in the extrahepatic bile ducts, a detailed morphologic study of these lesions has not been done. We examined the bile duct mucosa in 42 pancreaticoduodenectomy specimens, 32 with neoplastic lesions and ten with inflammatory lesions of the extrahepatic bile ducts, to assess the prevalence and type of metaplastic lesions. For comparison, the common bile ducts from 10 autopsy cases were reviewed. Twenty of the 42 total cases (48%), 13 of the 32 neoplastic cases (40%), and 7 of the 10 inflammatory cases (70%) had metaplastic changes. Pyloric gland metaplasia was the most common type (16/20 cases; 80%), whereas intestinal metaplasia was seen in 1/20 cases (5%). A combination of pyloric gland and intestinal metaplasia occurred in 2/20 cases (10%), and squamous metaplasia plus the above-mentioned two types of metaplasia was seen in 1/20 cases (5%). None of the normal common bile ducts obtained from ten autopsies had metaplastic changes. Endocrine cells were identified in nine (56%) of 17 metaplastic lesions. In contrast, endocrine cells within the intramural glands were seen in only 2 of the 10 normal common bile ducts. Although a significant proportion of carcinomas (6/13 cases) was in close proximity to areas of metaplasia, we were unable to find dysplastic foci within the metaplastic glands or the metaplastic surface epithelium. Reactive atypical cells involved the surface biliary epithelium and intramural glands and were associated with inflammation and metaplastic changes. The presence of goblet, mucinous, squamous, and reactive atypical cells in association with hyperplasia of intramural glands in frozen sections or small biopsy specimens may be mistaken for malignancy; hence, recognition of these lesions is of diagnostic importance.

Computer-assisted complete three-dimensional reconstruction of the mammary ductal/lobular systems: implications of ductal anastomoses for breast-conserving surgery

BACKGROUND

The intraductal spread of breast carcinoma can occur along the mammary ductal/lobular systems (MDLS) with no invasion of tissues. Because ductal anastomoses in the MDLS are considered to be a possible risk factor for extensive intraductal spread of breast carcinoma, the architecture of the MDLS has important therapeutic implications for patients treated with breast-conserving surgery.

METHODS

An entire breast resected by subcutaneous mastectomy from a 69-year-old woman with ductal carcinoma in situ (DCIS) was examined in submacroscopic sections by stereomicroscopic and histologic techniques. Serial 2-mm sections underwent computer-assisted complete three-dimensional reconstruction of all MDLS.

RESULTS

The entire breast that was studied contained 16 MDLS that were arranged radially, with the nipple at the center. Of these 16 MDLS, 4 (25.0%) had ductal anastomoses whereas the remaining 12 MDLS had no ductal anastomoses and completely independent regional anatomy. Ductal anastomoses were observed at 11 sites in the 4 MDLS. The 2 of 11 ductal anastomoses that connected different MDLS (18.2%) were situated > 4 cm from the nipple. The remaining nine ductal anastomoses connected ducts within the same MDLS; their location varied from near the nipple to the peripheral region. In the specimen examined, DCIS extended only within a single MDLS and did not spread between different MDLS via ductal anastomoses.

CONCLUSIONS

To the authors' knowledge, the current study is the first time the complete architecture of all MDLS in an entire breast has been studied three-dimensionally. The risk of promoting the intraductal spread of disease during surgery may be greater when intraductal lesions extend more peripherally than centrally. The features of ductal anastomoses may provide a significant anatomic clue regarding negative surgical margins in breast-conserving surgery.

Management of hilar cholangiocarcinoma: comparison of an American and a Japanese experience

OBJECTIVE

To compare the experience and outcome in the management of hilar cholangiocarcinoma at one American and one Japanese medical center.

SUMMARY BACKGROUND DATA

Controversies surround the issues of extent of resection for hilar cholangiocarcinoma and whether the histopathology of such cancers are similar between patients treated in America and in Japan.

METHODS

Records were reviewed of 100 patients treated between 1980 and 1995 at the Lahey Clinic in the United States, and of 155 patients treated between 1977 and 1995 at Nagoya University Hospital in Japan. Selected pathologic slides of resected cancers were exchanged between the two institutions and reviewed for diagnostic concordance.

RESULTS

In the Lahey cohort, there were 25 resections, 53 cases of surgical exploration with biliary bypass or intubation, and 22 cases of percutaneous transhepatic biliary drainage or endoscopic biliary drainage without surgery. In the Nagoya cohort, the respective figures were 122, 10, and 23. The overall 5-year survival rate of all patients treated (surgical and nonsurgical) during the study periods was 7% in the Lahey cohort and 16% in the Nagoya cohort. The overall 10-year survival rates were 0% and 12%, respectively. In patients who underwent resection with negative margins, the 5- and 10-year survival rates were 43% and 0% for the Lahey cohort and 25% and 18% for the Nagoya cohort. The surgical death rate for patients undergoing resection was 4% for Lahey patients and 8% for Nagoya patients. Of the patients who underwent resection, en bloc caudate lobectomy was performed in 8% of the Lahey patients and 89% of the Nagoya patients. Histopathologic examination of resected cancers showed that the Nagoya patients had a higher stage of disease than the Lahey patients.

CONCLUSIONS

In both Lahey and Nagoya patients, survival was most favorable when resection of hilar cholangiocarcinoma was accomplished with margin-negative resections. Combined bile duct and liver resection with caudate lobectomy contributed to a higher margin-negative resection rate in the Nagoya cohort.

A subcutaneous or subfascial jejunostomy is beneficial in the surgical management of extrahepatic bile duct cancers

BACKGROUND

Extrahepatic bile duct cancers are rare tumors with a dismal prognosis. Even after a resection, obstructive cholestasis and other biliary complications are the rule. To facilitate retrograde access to the biliary tree for treatment of such biliary complications, a modified Roux-en-Y hepaticojejunostomy is constructed such that the afferent limb is brought up as a subcutaneous or subfascial jejunostomy (SJ). The safety and utility of construction of an SJ was evaluated in patients with extrahepatic cholangiocarcinoma.

METHODS

From 1985 to 1997, 24 patients with extrahepatic bile duct cancers received an SJ as part of their management. Demographic data, operative data, tumor characteristics, and postoperative courses were retrospectively reviewed. All but 3 patients were followed to the time of death.

RESULTS

The average age of the patients was 62 +/- 9 years. The tumor was resected in 17 patients. Major complications occurred in 5 patients (21%). There was 1 operative death (4%). None of the complications could be attributed to construction of the SJ, although 1 patient had a soft tissue infection at the site of the percutaneous access of the SJ. Frequent dilatations of biliary strictures were required in 5 patients, and 1 patient eventually required insertion of an internal biliary stent. These procedures could all be accomplished through the SJ.

CONCLUSIONS

The SJ is a technically simple and safe addition to the management of resectable and unresectable extrahepatic bile duct cancers, particularly proximal lesions. The procedure facilitates brachytherapy if indicated, and it allows convenient management of postoperative biliary complications, including recurrent strictures.

Neoadjuvant photodynamic therapy before curative resection of proximal bile duct carcinoma

BACKGROUND

Hilar bile duct carcinoma has an 80% probability of local recurrence after curative resection, which might be reduced if neoadjuvant photodynamic therapy is feasible. CASE AND TREATMENT: After intravenous injection of sodium porfimer we treated an adenocarcinoma of the proximal common bile duct (T2 N0 M0, Bismuth type II) in a 72-year-old man with red laser light (applied from the lumen at a dose 250 Joules/cm2), and the adjacent right and left hepatic and common bile duct at a dose of 125 Joules/cm2. After 23 days the tumor was completely resected (adenocarcinoma pT2 pNO; G2).

RESULTS

In the lumenal, 4-mm-thick layer the bile duct specimen exhibited complete tumor necrosis with pigmentation of photodegraded porfimer and no viable tumor cells, while in the outer layer of the wall (at 5-8-mm depth) viable cancer cell nests without degraded porfimer were seen. The bile duct tissue showed little damage. Eighteen months after surgery, neither tumor recurrence nor stricture formation was found at the pretreated bilioenteric anastomoses.

CONCLUSIONS

a) Photodynamic therapy with sodium porfimer seems to be confined to the superficial 4-mm layer of bile duct cancer. b) Neoadjuvant photodynamic therapy is feasible for hilar bile duct carcinoma.

Photodynamic therapy for advanced bile duct cancer: evidence for improved palliation and extended survival

Median survival time of nonresectable hilar bile duct cancer is only 4 to 6 months owing to tumor spread in the biliary tree, refractory cholestasis, and sepsis or liver failure. We explored whether local photodynamic therapy of nonresectable bile duct cancer could improve survival. A sample size of 23 patients is required to detect an increase in 6-month survival rate from less than 50% to greater than 70% in a single-arm phase-II trial with a statistical power of 80% (Fleming's single step procedure; alpha = 0.05). Twenty-three consecutive patients (8 women, 15 men; 67 +/- 14 years) with nonresectable bile duct cancer (Bismuth type III n = 2, type IV n = 21) were treated with photodynamic therapy and biliary endoprosthesis. Photofrin (QLT Pharmaceuticals, Vancouver, Canada) (2 mg/kg body weight intravenously) was photoactivated after 1 to 4 days with laser light (630 nm; 242 J/cm(2)) via endoscopic retrograde access. The 6-month survival rate was 91% after diagnosis and 74% after start of photodynamic therapy (30-day mortality rate was 4%) at a median follow-up time of 10.3 months after diagnosis. Causes of death were tumor progression (n = 9) and bacterial infections (n = 4). The median rate of local tumor response was 74%, 54%, 29%, and 67% after the first, second, third, fourth, and fifth photodynamic therapy. Time to progression ranged from 3 to 8 months. All patients, except 1 with diffuse liver metastases, improved in cholestasis, performance, and quality of life. Photodynamic therapy can prevent tumor occlusion of hilar bile ducts. The apparent benefit in survival time should be confirmed in a controlled trial versus palliation by endoprosthesis only.

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

No Abstract Available

SEA-scFv as a bifunctional antibody: construction of a bacterial expression system and its functional analysis

A SEA-antibody single chain Fv (SEA-scFv) fusion protein was produced by bacterial expression system in this study. SEA-scFv has both staphylococcal enterotoxin A (SEA) effects and antibody activity directed at the epithelial mucin core protein MUC1, a cancer associated antigen. It was expressed mostly in the cytoplasm as an insoluble form. The gene product was solubilized by guanidine hydrochloride, refolded by conventional dilution method, and purified using metal-chelating chromatography. The resulting SEA-scFv fusion protein preparation was found to react with MUC1 and MHC class II antigens and had the ability to enhance cytotoxicity of lymphokine activated killer cells with a T cell phenotype against a human bile duct carcinoma cell line, TFK-1, expressing MUC1. This genetically engineered SEA-scFv fusion protein promises to be an important reagent for cancer immunotherapy.

The role of chemotherapy and radiation in the management of biliary cancer: a review of the literature

Carcinoma of the biliary tract is a rare tumour. To date, there is no therapeutic measure with curative potential apart from surgical intervention. Thus, patients with advanced, i.e. unresectable or metastatic disease, face a dismal prognosis. They present a difficult problem to clinicians as to whether to choose a strictly supportive approach or to expose patients to the side-effects of a potentially ineffective treatment. The objective of this article is to review briefly the clinical trials available in the current literature utilising non-surgical oncological treatment (radiotherapy and chemotherapy) either in patients with advanced, i.e. locally inoperable or metastatic cancer of the biliary tract or as an adjunct to surgery. From 65 studies identified, there seems to be no standard therapy for advanced biliary cancer. Despite anecdotal reports of symptomatic palliation and survival advantages, most studies involved only a small number of patients and were performed in a phase II approach. In addition, the benefit of adjuvant treatment remains largely unproven. No clear trend in favour of radiation therapy could be seen when the studies included a control group. In addition, the only randomised chemotherapeutic series seemed to suggest a benefit of treatment in advanced disease, but due to the small number of patients included, definitive evidence from large, randomised series concerning the benefit of non-surgical oncological intervention as compared with supportive care is still lacking. Patients with advanced biliary tract cancer should be offered the opportunity to participate in clinical trials.

Aggressive surgical approaches to hilar cholangiocarcinoma: hepatic or local resection?

BACKGROUND

It has been reported that surgical excision of hilar cholangiocarcinoma rather than palliative surgical therapy, chemotherapy, or radiotherapy caused prolonged survival in some patients, However, excision is associated with high operative morbidity and mortality rates, particularly when hepatic resection is also performed. The aim of this study was to evaluate the clinical implications of hepatic resection in hilar cholangiocarcinoma.

METHODS

The study involved 76 patients with hilar cholangiocarcinoma who were undergoing surgical resections. Twenty-one patients (28%) underwent a combined resection, with reconstruction of the portal vein in 20 patients and reconstruction of the hepatic artery in 7 patients. Sixty-five patients undergoing seven different types of hepatic resection with extrahepatic bile duct resection (BDR) and 11 patients undergoing BDR only were retrospectively compared for background, operative morbidity and mortality, and survival.

RESULTS

Curative resection was obtained in 5 of 11 (45%) patients undergoing local resection and in 49 of 65 (75%) patients undergoing hepatic resection (p < 0.05). The surgical morbidity rates were 34% and 27% for hepatic and local resection, respectively. The 30-day mortality and hospital mortality rates were 4.6% and 15% for hepatic resection and 0% and 0% for local resection, respectively. The 5-year survival rate was 26% for all resected patients (76 patients); it was 40% versus 0% for curative versus noncurative resections (p < 0.05). No significant difference in surgical resection rates was revealed between hepatic and local resection among resected and curative resected patients.

CONCLUSIONS

Aggressive surgical approaches to obtain curative resections could bring about a better prognosis in hilar cholangiocarcinoma independently of whether hepatic resection or local resection is performed.

Surgical strategies for carcinoma of the hepatic duct confluence

BACKGROUND

This study was conducted to clarify the clinicopathological factors influencing appropriate surgical strategy and survival in patients with carcinoma of the hepatic duct confluence.

METHODS

A total of 66 patients who underwent local resection of the bile duct with (n = 44) and without (n = 22) hepatectomy were reviewed retrospectively.

RESULTS

Fifteen of the 44 patients who had hepatectomy and two of the 22 who did not suffered major postoperative complications (P < 0.05). As the pT category rose, the incidence of microscopic tumour extension increased significantly. Invasion at the surgical margins was more frequent in the patients who did not have hepatectomy than in those who did. Extramural tumour extension was found in 23 of 28 patients, and its prevalence was higher in the hepatic direction than the duodenal direction. Cancer invasion to the caudate lobe was found in nine of 21 patients. Thirty of 44 patients who underwent hepatectomy had a curative resection compared with six of 22 who did not have hepatectomy (P < 0.01). The cumulative survival rates after curative resection were significantly higher than after non-curative resection (P < 0.01).

CONCLUSION

Hepatectomy with caudate lobectomy improves the curability and prognosis because these tumours frequently invade the surgical margins. However, operative morbidity is higher with this procedure.

Liver resection for hilar and peripheral cholangiocarcinomas: a study of 62 cases

OBJECTIVE

To analyze a single center's 14-year experience with 62 consecutive patients with hilar (HCCA) and peripheral (PCCA) cholangiocarcinomas.

SUMMARY BACKGROUND DATA

Long-term survival after surgical treatment of HCCA and PCCA has been poor.

METHODS

From March 1981 until December 1994, 62 consecutive patients with HCCA (n = 28) and PCCA (n = 34) underwent surgical treatment. The operations were individualized and included local excision of the tumor and suprapancreatic bile duct, lymph node dissection, vascular reconstruction, and subtotal hepatectomy. Clinical and pathologic risk factors were examined for prognostic influence.

RESULTS

Patients were followed for a median of 25 months (12-102 months). Postoperative morbidity and mortality (at 30 days) were 32% and 14%, respectively, for HCCA and 24% and 6% for PCCA. The survival rates for HCCA and PCCA were 79% (+/-8%) and 67% (+/-8%) at 1 year; 39% (+/-10%) and 40% (+/-9%) at 3 years; and 8% (+/-7%) and 35% (+/-10%) at 5 years, respectively. The median survival was 24 (+/-4) months for HCCA and 19 (+/-8) months for PCCA. The disease-free survival rates for HCCA and PCCA were 85% (+/-10%) and 77% (+/-9%) at 1 year; 18% (+/-11%) and 41% (+/-12%) at 3 years; and 18% (+/-11%) and 41% (+/-12%) at 5 years, respectively. Nearly 80% of these patients had TNM stage IV tumors. With HCCA, no risk factors were associated with patient survival. For PCCA, multiple tumors (relative risk [RR] = 3.5; 95% confidence interval [CI] = 1.2-10.5) and incomplete resection (RR = 8.3; 95% CI = 2.3-29.6) were independently associated with a worse prognosis. For HCCA, there was a trend for lower disease-free survival in females (p = 0.056; log rank test). For PCCA, tumor size >5 cm was the only factor associated with disease recurrence (p = 0.024; log rank test).

CONCLUSIONS

Even though rare, 5-year survival by resection can be achieved in both HCCA and PCCA, but new adjuvant treatments are clearly needed.

Three-dimensional reconstruction of biliary tract from biplane projections

Over the past few years, very little has been done in the area of 3-D reconstruction of the bile duct. Since the system in use for 3-D visualization of the biliary tree is built by surgical or autopsy materials, it generally cannot be applied to clinical diagnosis. In this paper, an algorithm for three-dimensional reconstruction of the biliary tree from two mutually orthogonal is presented to provide accurate and reproducible 3-D information of the biliary tree structure. It has been proven to be useful in diagnosis prior to operation or non-surgical treatment, particularly, obstructive stones can be visualized by using a transparency technique. As experiments demonstrated, the proposed method can be used as a useful tool for the visualization of 3-D structure of biliary tree in clinical applications.

Liver, gallbladder, extrahepatic bile ducts, and pancreas

BACKGROUND

The liver, gallbladder, bile ducts, and pancreas have a common embryologic origin; cancers that arise from these sites therefore are expected to share a similar spectrum of histologic types. These cancers are known for their extremely poor prognoses.

METHODS

Data from the Surveillance, Epidemiology, and End Results Program regarding the incidence, distribution of histologic types, stage of disease, and survival for cancers of the gallbladder (n = 4412), extrahepatic bile ducts (n = 3486), pancreas (n = 23,116), and liver (n = 6,391) were reviewed. The most common histologic types are discussed, and the frequency of rare types is reported.

RESULTS

The incidence of biliary cancer decreased, while the incidence of hepatic and pancreatic cancer rose slightly over the 15-year period from 1973 to 1987. Age and sex distributions varied by histologic type. Greater than 98% of pancreatic and biliary cancers were carcinomas, and adenocarcinoma (not otherwise specified) was the most common histologic type recorded. In the liver, hepatocellular carcinoma was the most common type, followed by intrahepatic cholangiocarcinoma. The overall 5-year relative survival rates for these cancers were very low: gallbladder, 12.3%; extrahepatic bile duct, 12.7%; liver 3.1%; and pancreas 2.5% (all stages combined, 1978-1986).

CONCLUSIONS

This review confirmed that these carcinomas are associated with a very poor outcome; however, survival was influenced by stage of disease and histologic type. In the gallbladder and extrahepatic bile ducts, papillary adenocarcinoma was associated with the best outcome of all histologic types, and in the exocrine pancreas, mucinous cystadenocarcinoma was associated with the best prognosis.

Computer-assisted pathology of intraepithelial adenocarcinoma and related lesions: 3-D distribution, structural aberration and discrimination

To discriminate among intraepithelial neoplasms, we have been relying on tissue microscopy, but pathologists' subjectivity sometimes impairs diagnosis. Even an individual pathologist is sometimes unable to reproduce exactly his or her own previous diagnosis. Are various atypical lesions classifiable in a reproducible way, and if they are, how? The reliability of a diagnosis will be strengthened if we can define the "natural" categories inherent in cells and tissues. Morphometry and statistical analysis using a computer can provide answers. Atypia, a morphological feature of carcinoma, is essentially multivariate. Quantification of a tissue feature requires reducing it to a set of ten or more quantities, including size, shape and position of the nucleus, nucleolus, and the cell itself. The grade of aberration from the norm can be assessed only by a synthetic approach, using a computer for multivariate cluster analysis. This classification has been attempted in adenocarcinoma and related lesions of the lung and pancreas. The categories thus established are reproducible, because the lesions fall into divisions according to their forms. We can also examine the organ distribution of intraepithelial neoplasms by three dimensional (3-D) computer-assisted mapping. To reach a higher level of reliability, as many meaningful features as possible should be taken into account. Particularly, we emphasize the significance of architectural pattern as a biomarker for intraepithelial glandular neoplasms. Computer-aided 3-D structural analysis visualizes the basic skeleton of these neoplasms around which the cells adhere. Instead of the dichotomous tree pattern of normal glands, the tumors basically harbor a 3-D network, tubular or porous, which increasingly deviates from the norm along with the transition from adenoma to well to moderately to poorly differentiated adenocarcinoma. This structural aberration, if recognizable on 2-D sectional images, will serve as a surrogate endpoint biomarker for glandular tumors.

Invasive growth patterns of hepatic hilar ductal carcinoma. A histologic analysis of 18 surgical cases

BACKGROUND

Postoperative recurrence of hepatic hilar ductal carcinoma usually occurs in a localized region around the surgical margin, such as the bile duct. This study was aimed at assessing the invasive patterns of the hepatic hilar ductal carcinoma by histologically examining surgical specimens obtained by extended liver resection, especially the involvement of intrahepatic duct.

METHODS

Eighteen resected specimens of hepatic hilar ductal carcinoma were histologically investigated. Multiple sections vertical to the extrahepatic and intrahepatic bile duct were made at a 5-mm interval. The extension of carcinoma was evaluated on each of three layers (mucosal, extramucosal-intramural, and extramural), and routes of the invasion were examined.

RESULTS

Extramucosal extent toward the hepatic side was observed in 14 patients (77.8%) and that toward the duodenal side in 8 patients (44.4%) (P < 0.05). The distance of extramucosal tumor extent was also significantly longer (P < 0.05) in the hepatic side than in the duodenal side. Histologic tumor margin was usually identified in the extramural layer. Two patients had discontinuous extramucosal invasion. The lymphatic invasions were observed most frequently, followed by perineural invasion, and venous invasion was rare. In the extramucosal invasion of the liver, the left dominant carcinomas had extended toward the left, whereas those right dominant had extended toward the right (P < 0.05). Well differentiated differentiated tubular adenocarcinomas extended to the liver more extensively than moderately and poorly differentiated ones, but not significantly.

CONCLUSIONS

The authors examined the extramucosal invasion of hepatic hilar ductal carcinoma. This invasion extended more frequently and further to the hepatic side than to the duodenal side, usually by the route of the extramural layer.

Observations supporting the existence of true local metastases of cancer

We propose the hypothesis that around a main invading tumor, there are local metastases in the surrounding tissue/organ. They occur as a result of cancer cell migration through the interstitial matrix and we call them true local metastases. They are composed of individual or nested cells but are difficult to identify because of their nonspecific appearance, close location to the irregular surface of the main tumor and observer's inability to deduce a three dimensional structure from a few two-dimensional histological pictures. The propensity of neoplasms to locally metastasize may vary greatly among different types and stages of tumors. Better knowledge of a tumor's three dimensional spread may influence treatment strategy.

Carcinoma of the extrahepatic bile ducts. Histologic types, stage of disease, grade, and survival rates

Data on patients with extrahepatic bile duct carcinomas recorded in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute were reviewed. We analyzed the records of 1766 patients reported during a 10-year period (1977-1986). These tumors occurred primarily in older age groups and were slightly more common in males. Histologic grade, histologic types, and stage of disease are useful prognostic indicators. The 5-year survival rate for patients with Stage I disease was 11%. Although carcinomas of the extrahepatic bile ducts are better differentiated than carcinomas arising in the gallbladder, they have a less favorable prognosis.

The WHO Histological Classification of Tumors of the Gallbladder and Extrahepatic Bile Ducts. A commentary on the second edition

The second edition of the WHO Histological Classification of Tumors of the Gallbladder and Extrahepatic Bile Ducts is more comprehensive and detailed than the previous one. Advances in our understanding of dysplasia, carcinoma in situ, various lines of differentiation among the carcinomas, and the recognition of a variety of tumor-like lesions have resulted in more than three times as many entities in the current classification as in the previous one. The new edition should facilitate pathologic, epidemiologic, and therapeutic comparisons.