Multimodality therapy for locoregional extrahepatic cholangiocarcinoma: a population-based analysis

Neoadjuvant and adjuvant therapy for biliary tract cancer: Advances and limitations

Biliary tract cancers (BTC) are a rare and aggressive consortium of malignancies, consisting of intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, and gallbladder carcinoma. While most patients present with metastatic disease, a minority of patients with BTC are eligible for curative surgical resection at the time of presentation. However, these patients have poor 5-year overall survival rates and high rates of recurrence, necessitating the improvement of the neoadjuvant and adjuvant treatment of BTC. In this review, we assess the neoadjuvant and adjuvant clinical trials for the treatment of BTC and discuss the challenges and limitations of clinical trials, as well as future directions for the treatment of BTC.

Examining the Use of Radiation Therapy for Cholangiocarcinoma: Benefits through Modern Techniques

BACKGROUND

Cholangiocarcinoma (CCA) is a rare malignant tumor of the bile duct epithelium. At first diagnosis, only a minority of patients are eligible for surgery, which is regarded as the only curative treatment. This study examines the role of radiation therapy (RT) and chemoradiotherapy (CRT) in the definitive and adjuvant treatment situation.

METHODS

The monocentric, retrospective analysis included 39 patients with CCA undergoing 53 RT courses. Data were collected from January 2005 to September 2018. There were 11 cases of CRT, 6 of which were definitive. Surgery was either palliative (n = 6) or radical (n = 15).

RESULTS

After RT, the median overall survival (OS) was 10.4 months (m), median progression-free survival was 5.6 m, and median duration of local control (DOLC) was 8.9 m. There was a significant difference in survival between patients with and without locoregional lymph node metastasis (OS: 4.3 vs. 15.4 m, p = 0.031). After treatment of a primary tumor, DOLC was about twice as long as in the recurrent situation (10.4 vs. 5.4 m, p = 0.032). Conservative therapy significantly elevated the risk of local recurrence compared to radical surgery in univariate and multivariate analyses. Side effects were mostly classified as mild to moderate. Termination of RT and increased alanine aminotransferase were significantly less frequent after stereotactic body radiation therapy and hypofractionation.

CONCLUSION

RT can achieve local control in patients with CCA. Toxicities of RT are manageable but require close clinical and laboratory follow-up.

The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer

Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.

Multimodality treatment in unresectable cholangiocarcinoma

Purpose

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

Material and methods

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

Results

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

Conclusions

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

Development and validation of a nomogram for survival benefit of lymphadenectomy in resected gallbladder cancer

Background

Due to absence of large, prospective, randomized, clinical trial data, the potential survival benefit of lymphadenectomy with different number of regional lymph nodes (LNs) remains controversial. We aim to create a predicting model to help estimate individualized potential survival benefit of lymphadenectomy with more regional LNs for patients with resected gallbladder cancer (GBC).

Methods

Patients with resected GBC were selected from the Surveillance, Epidemiology, and End Results database who were diagnosed between 2004 and 2014. Covariates included age, race, sex, grade, histological stage, tumor sizes and receipt of non-primary surgery. Two types of multivariate survival regression models were constructed and compared. The best model performance was tested by the external validation data from our hospital.

Results

A total of 1,669 patients met the inclusion criteria for this study. The lognormal survival model showed the best performance and was tested by the external validation data, including 193 patients with resected GBC from our hospital. Nomograms, which based on the accelerated failure time parametric survival model, were built to estimate individualized survival. C-index, was up to 0.754 and 0.710 in internal validation for more and less regional LNs removed, respectively. Both of internal and external calibration curves showed good agreement between predicted and observed outcomes in the 1-, 3-, and 5-year overall survival (OS).

Conclusions

A predicting model can be used as a decision model to predict which patients may obtain benefit from lymphadenectomy with more regional LNs.

The role of preoperative therapy prior to pancreatoduodenectomy for distal cholangiocarcinoma

BACKGROUND

Although increasingly administered to patients with pancreatic ductal adenocarcinoma, the role of preoperative therapy for patients with distal cholangiocarcinoma is undefined.

METHODS

All patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy between 1999 and 2014 were retrospectively reviewed. Differences in clinicopathologic characteristics and overall survival (OS) were compared between patients who underwent surgery de novo and those who received preoperative therapy.

RESULTS

Twenty-one patients (46.7%) received preoperative therapy and 24 (53.3%) did not. Five-year OS rates were not statistically significantly different between patients who received preoperative therapy and those who did not (46.6% vs 49.1%, p > 0.05). On multivariate cox proportional hazards analysis, lymph node positivity was the strongest predictor of OS (HR 4.68 (95%CI 1.52-14.42)). Whereas preoperative therapy was not associated with improved OS (HR 1.06 (95%CI 0.42-2.66)), the receipt of either pre- or post-operative therapy was (HR 0.40 (95%CI 0.16-1.00)).

CONCLUSION

While these results do not support the routine administration of preoperative therapy to patients with distal cholangiocarcinoma, it may be an alternative treatment strategy appropriate for a subset of patients with high risk clinical or pathologic features.

Adjuvant Therapy for Biliary Tract Cancers

Biliary tract cancers, including gallbladder cancer, intrahepatic, perihilar, and distal cholangiocarcinomas, although anatomically contiguous, represent a heterogeneous group of cancers with extensive biologic and genetic diversity. With early disease, surgical resection is the preferred option for all subtypes; however, relapse rates remain high, and survival outcomes are poor. Data to guide the use of adjuvant therapy have been limited to retrospective series, population-based studies, and meta-analyses, all with their associated limitations. The number of prospective trials ongoing or completed is increasing, and these results will ultimately dictate optimal treatment of this group of diseases. This review summarizes the data for adjuvant therapy in biliary tract cancers.

Liver Transplant for Cholangiocarcinoma

Liver transplant (LT) for perihilar cholangiocarcinoma (CCA) offers an opportunity for survival among patients with early-stage but anatomically unresectable disease. The 5-year survival rate after LT is 65% to 70%, higher among patients with primary sclerosing cholangitis, who are often diagnosed earlier, and lower among patients with de novo CCA. The results of LT for hilar CCA, along with recent limited data suggesting favorable survival among patients with very early intrahepatic CCA (ICC), have reignited interest in the subject. This article discusses LT following neoadjuvant therapy for CCA and the early data on LT alone for ICC.

External radiotherapy and brachytherapy in the management of extrahepatic and intrahepatic cholangiocarcinoma: available evidence

This review aims to summarize the currently available evidence for the role of external radiotherapy and brachytherapy in the management of cholangiocarcinoma. High locoregional disease recurrence rates after surgical resection alone for both the extrahepatic cholangiocarcinoma (EHCC) and intrahepatic cholangiocarcinoma (IHCC) provide a rationale for using adjuvant radiotherapy with chemotherapy. We performed a literature search related to radiotherapy in cholangiocarcinoma published between 2000 and 2016. The role of radiation is discussed in the adjuvant, neoadjuvant, definitive and the palliative setting. Evidence from Phase II trials have demonstrated efficacy of adjuvant chemoradiation in combination with chemotherapy in EHCC. Locally advanced cholangiocarcinoma may be treated with neoadjuvant chemoradiotherapy. In the case of downsizing, assessment for resection may be considered. Brachytherapy offers dose escalation after external radiotherapy. Selected unresectable cases of cholangiocarcinoma may be considered for stereotactic body radiation therapy with neoadjuvant and/or concurrent chemotherapy. Liver transplantation is a treatment option in selected patients with EHCC and IHCC after neoadjuvant chemoradiation. Stenting in combination with palliative external radiotherapy and/or brachytherapy provides improved stent patency and survival. Newer advanced radiation techniques provide a scope for achieving better disease control with reduced morbidity. Effective multimodality treatment incorporating radiotherapy is the way forward for improving survival in patients with cholangiocarcinoma.

Expression and prognostic value of glutamate dehydrogenase in extrahepatic cholangiocarcinoma patients

Glutamate dehydrogenase (GDH) produces a precursor to glutathione, an important molecule in maintaining cellular redox balance and the cancerous characteristics of tumor cells through intracellular signaling pathways. However, the underlying molecular mechanisms linking glutamate dehydrogenase and extrahepatic cholangiocarcinoma have not been elucidated yet. Herein, we examined GDH expression levels and evaluated its potential correlations with prognosis. Meanwhile, the therapeutic value of GDH targeting the Smad pathways in extrahepatic cholangiocarcinoma was explored. Immunohistochemical studies revealed that GDH expression level was correlated to CD34 expression, cellular differentiation, the presence or absence of capsular and vascular invasion, lymph node metastasis, neural invasion and patient age. Kaplan-Meier survival analysis and COX proportional hazards models demonstrated that the prognosis was closely associated with GDH expression, CD34 positivity, nerve infiltration and cell differentiation. GDH silencing significantly reduced the proliferation, migratory potential and invasive capability. We also demonstrated that GDH promoted cell proliferation and metastasis potentially through Smad-mediated induction of TGF-β signaling pathway. Therefore, GDH may be an important prognostic indicator and may provide a new target for novel treatments of extrahepatic cholangiocarcinoma.

Adjuvant therapy in biliary tract and gall bladder carcinomas: a review

Biliary tract carcinomas are relatively rare, but are increasingly diagnosed. They comprise several anatomically contiguous sites, so are often grouped together, but they do appear to represent distinct diseases, in part because of anatomical and surgical considerations. Complete upfront surgical resection is generally difficult because these cancers are often diagnosed at relatively advanced stages of disease. Thus, adjuvant therapy is often considered. This paper will review the evidence underpinning current recommendations for adjuvant therapy in biliary carcinomas.

Does radiotherapy still have a role in unresected biliary tract cancer?

The benefits of radiotherapy for inoperable biliary tract cancer remain unclear due to the lack of randomized data. We evaluated the impact of radiotherapy on survival in elderly patients using the SEER‐Medicare database. Patients in the SEER‐Medicare database with inoperable biliary tract tumors diagnosed between 1998 and 2011 were included. We used multivariate logistic regression to evaluate factors associated with treatment selection, and multivariate Cox regression and propensity score matching to evaluate treatment selection in relation to subsequent survival. Of the 2343 patients included, 451 (19%) received radiotherapy within 4 months of diagnosis. The use of radiotherapy declined over time, and was influenced by receipt of chemotherapy and patient age, race, marital status, poverty status, and tumor stage and type. Median survival was 9.3 (95% CI 8.7–9.7) months among patients who did not receive radiation and 10.0 (95% CI 9.1–11.3) months among those who received radiation, conditional on having survived 4 months. In patients who received chemotherapy (n = 1053), receipt of radiation was associated with improved survival, with an adjusted hazard ratio of 0.82 (95% 0.70–0.97, P = 0.02). In patients who did not receive chemotherapy (n = 1290), receipt of radiation was not associated with improved survival, with an adjusted hazard ratio of 1.09 (95% 0.91–1.30, P = 0.34). Propensity‐scored matched analyses showed similar results. Despite the survival benefit associated with the addition of radiotherapy to chemotherapy, the use of radiation for unresectable biliary tract cancers has declined over time.

Comparison of external beam radiation and brachytherapy to external beam radiation alone for unresectable extrahepatic cholangiocarcinoma

BACKGROUND

Extrahepatic cholangiocarcinoma (EHC) is a rare malignancy with a relatively poor prognosis. There are no randomized, prospective data to help define the optimal method of radiation delivery for unresectable EHC. The purpose of this study was to evaluate the benefit of adding brachytherapy to external beam radiation therapy (EBRT) for unresectable EHC.

METHODS

A retrospective review of 1,326 patients with unresectable EHC using the Surveillance, Epidemiology, and End Results (SEER) database was completed. Kaplan-Meier methods were used to analyze the primary endpoint, overall survival. Univariate and multivariate analysis was performed to identify and control for potential confounding variables, including age at diagnosis, sex, stage, grade, histology, race, year of diagnosis, and reason for no surgery.

RESULTS

Of the 1,326 patients with unresectable EHC, 1,188 (92.9%) received EBRT only, while 91 (7.1%) received both EBRT and brachytherapy. Patients receiving combined modality radiation therapy were more likely to be treated prior to the year 2000. Median overall survival for patients receiving EBRT and EBRT plus brachytherapy was 9 and 11 months, respectively (P=0.04). Cause specific survival was 12 months for those receiving EBRT only, and 15 months for those who received EBRT + brachytherapy (P=0.10). Survival analysis performed on patients with locoregional disease only revealed a trend towards prolonged overall survival with those receiving EBRT + brachytherapy (P=0.08). Multivariate analysis revealed grade and stage of disease were correlated with both overall survival and cause specific survival (P≤0.05).

CONCLUSIONS

Among patients with unresectable EHC, the addition of brachytherapy to EBRT is associated with a prolonged median overall survival. However, the use of brachytherapy boost decreased in the last decade of the study.

Radiation therapy in cholangiocellular carcinomas

Cholangiocarcinoma can arise in all parts of the biliary tract and this has implications for therapy. Surgery is the mainstay of therapy however local relapse is a major problem. Therefore, adjuvant treatment with chemoradiotherapy was tested in trials. The SWOG-S0809 trial regimen of chemoradiotherapy which was tested in extrahepatic cholangiocarcinoma and in gallbladder cancer can currently be regarded as highest level of evidence for this indication. In contrast to adjuvant therapy where only conventionally fractionated radiotherapy plays a role, stereotactic body radiotherapy (SBRT) today has become a powerful alternative to chemoradiotherapy for definitive treatment due to the ability to administer higher doses of radiotherapy to improve local control. Sequential combinations with chemotherapy are also frequently employed. Nevertheless, in general cholangiocarcinoma is an orphan disease and future clinical trials will have to improve the available level of evidence.

A long survivor with local relapse of hilar cholangiocarcinoma after R1 surgery treated with chemoradiotherapy: a case report and literature review

The treatment outcome of extrahepatic cholangiocarcinoma remains insufficient because it is difficult to obtain accurate diagnosis of tumor spreading and effective treatment agent is quite limited in spite of substantial current efforts, all of which have been unsuccessful except for gemcitabine plus cisplatin. The patient was a 60-year-old female who had developed hilar cholangiocarcinoma and underwent extrahepatic bile duct resection. Although it was conceivable that it would be the R1 resection, the patient wanted to receive limited resection to avoid postoperative complication mainly because she was depressed. In histology, interstitial spreading of tumor was appreciated at the surgical margin of bile duct. The patient did not accept to receive the additional treatment after the surgery and hardly visited the hospital to take the periodical test for monitoring the residual cancer cells. As expected, the local relapse of tumor was appreciated 1 year after the R1 surgery. She chose radiotherapy and agreed with subsequent S-1 treatment for 26 months. Consequently, elevated CA19-9 was decreased, and local relapse has been successfully controlled for more than 7 years after the relapse of tumor. Here, we report quite a rare case in terms of long survivor after chemoradiotherapy on locally relapsed unresectable hilar cholangiocarcinoma.

Prognosis of hepatocellular carcinoma: Assessment of eleven staging systems

BACKGROUND & AIMS

Multiple staging systems have been proposed for hepatocellular carcinoma (HCC). However there is no consensus regarding which system provides the best prognostic accuracy. We aimed to investigate the performance of 11 currently used HCC staging systems.

METHODS

Between 2002 and 2013, a large prospective dataset of 3182 HCC patients were enrolled. The baseline characteristics and staging information were collected. Independent predictors of survival were identified. Homogeneity and corrected Akaike information criterion (AICc) were compared between each system.

RESULTS

The median follow-up duration was 17months. Independent predictors of adverse outcome were serum albumin <3.5g/dl, bilirubin ⩾1mg/dl, creatinine ⩾1mg/dl, alpha-fetoprotein ⩾20ng/ml, alkaline phosphatase ⩾200IU/L, presence of ascites, multiple tumor nodules, maximal tumor size >5cm, presence of vascular invasion, presence of extrahepatic metastasis, and poor performance status (all p<0.001). Significant differences in survival were found across all stages of the 11 systems except between Hong Kong Liver Cancer stage IV and V, Japan Integrated Staging score 4 and 5, and Tokyo score 5 through 8. The Cancer of the Liver Italian Program (CLIP) score was associated with the highest homogeneity and lowest AICc value in the entire cohort. In subgroup analysis, the CLIP score was also superior in patients with hepatitis B- or hepatitis C-related HCC and in patients receiving curative or non-curative treatments.

CONCLUSIONS

The CLIP staging system is stable and consistently the best prognostic model in all patients and in patients with different viral etiology and treatment strategy.

Proton beams in cancer treatments: Clinical outcomes and dosimetric comparisons with photon therapy

PURPOSE

To review current evidence of the role of proton therapy (PT) in other tumors than skull base, sinusal/parasinusal, spinal and pediatric tumors; to determine medico-economic aspects raised by PT.

MATERIAL AND METHODS

A systematic review on Medline was performed with the following keywords: proton therapy, proton beam, protontherapy, cancer; publications with comparison between PT and photon-therapy were also selected.

RESULTS

In silico studies have shown superiority (better dose delivery to the target and/or to organs at risk) of PT toward photon-therapy in most of thoracic and abdominal malignant tumors. Potential benefits of PT could be: reduction of toxicities (including radiation-induced cancer), increase of tumor control through a dose-escalation approach, hypofractionation. Cost of treatment is always cited as an issue which actually can be managed by a precise patient selection making PT a cost-effective procedure. Comparison plan with photon therapy may be useful to determine the dosimetric and clinical advantages of PT (Normal Tissue Complications Probability).

CONCLUSION

PT may be associated with a great advantage compared to the best photon-therapies in various types of cancers. Accumulation of clinical data is on-going and will challenge the in silico data analysis. Some indications are associated with strong superiority of PT and may be discussed as a new standard within prospective observational studies.

Hong Kong Liver Cancer Staging System Is Associated With Better Performance for Hepatocellular Carcinoma: Special Emphasis on Viral Etiology

Hong Kong Liver Cancer (HKLC) staging system was developed for prognostic and treatment evaluation for hepatocellular carcinoma (HCC) but is not externally validated. We aimed to evaluate and compare HKLC system with Barcelona Clínic Liver Cancer (BCLC) staging system. The prognostic performance, discriminatory ability, and efficacy of treatment recommendations were compared between the BCLC and HKLC systems. Significant differences in survival were found across all stages of BCLC and across stages I to IV of HKLC systems (P < 0.01). HKLC system was associated with higher homogeneity in prognostic accuracy. The survival was similar between patients treated according to the HKLC or BCLC system (P = 0.07). However, more patients were treated according to HKLC recommendations than to BCLC recommendations (57% vs. 47%, P < 0.001). In a hypothetical cohort created by random sampling, patients treated according to the HKLC scheme had better survival compared with patients treated according to the BCLC system (P < 0.001).Subgroup analyses between hepatitis B virus (HBV) and hepatitis C virus (HCV)-related HCC were performed. More HCV-related HCC were at earlier BCLC or HKLC stages (both P < 0.001). The HKLC system was more informative with greater homogeneity in predicting survival in both HBV and HCV cohorts. However, HKLC treatment recommendations were associated with better long-term survival only in HBV-related HCC but not in HCV-related HCC (P < 0.001 and P = 0.79, respectively).In conclusion, we provided external validation of the HKLC system. Compared with the BCLC system, the HKLC system has better prognostic accuracy and therapeutic efficacy in the entire cohort and in HBV-related HCC but not in HCV-related HCC. Due to high heterogeneity among patients of various etiologies, staging and treatment strategies tailored to specific HCC etiology are required.

Surgery Alone Versus Surgery Followed by Chemotherapy and Radiotherapy in Resected Extrahepatic Bile Duct Cancer: Treatment Outcome Analysis of 336 Patients

Purpose

This study analyzed the outcomes of patients with resected extrahepatic bile duct cancer (EHBDC) in order to clarify the role of adjuvant treatments in these patients.

Materials and Methods

A total of 336 patients with EHBDC who underwent curative resection between 2001 and 2010 were analyzed retrospectively. The treatment types were as follows: surgery alone (n=168), surgery with chemotherapy (CTx, n=90), surgery with radiotherapy (RT) alone (n=29), and surgery with chemoradiotherapy (CRT, n=49).

Results

The median follow-up period was 63 months. The 5-year rates of locoregional failure-free survival (LRFFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) for all patients were 56.5%, 59.7%, 36.6%, and 42.0%, respectively. In multivariate analysis, surgery with RT and CRT was a significant prognostic factor for LRFFS, and surgery with CTx was a significant prognostic factor for DMFS, and surgery with CTx, RT, and CRT was a significant prognostic factor for PFS (p < 0.05). Surgery with CTx and CRT showed association with superior OS (p < 0.05), and surgery with RT had marginal significance (p=0.078). In multivariate analysis of the R1 resection patients, surgery with CRT showed significant association with OS (p < 0.05).

Conclusion

Adjuvant RT and CTx may be helpful in improving clinical outcomes of patients with resected EHBDC who have a high risk of disease recurrence, particularly R1 resection patients. Conduct of additional prospective, larger-scale studies will be required in order to confirm the benefit of adjuvant RT and CTx in these patients.

Biliary stenting for unresectable cholangiocarcinoma: A population-based study of long-term outcomes and hospital costs in Taiwan

Few studies have compared percutaneous biliary stenting (PBS) and endoscopic biliary stenting (EBS) in terms of long-term effects on cholangiocarcinoma (CC), and few have systematically evaluated outcome associations in Taiwan. This study aimed to compare long-term outcomes between two treatments for unresectable CC: PBS and EBS. After propensity score matching (PSM) to reduce the effect of selection bias, 1002 CC patients were included in this analysis: 501 in the PBS group and 501 in the EBS group. The Kaplan-Meier method was used to construct the survival curve for all CC patients, and the Cox proportional hazards model was used for multivariate assessment of outcome predictors. After PSM, group comparisons revealed a significantly longer length of stay in the PBS group compared to the EBS group (25 days vs. 19 days, respectively; p < 0.001). Hospital costs were also significantly higher in the PBS group than in the EBS group (US$126,575 vs. US$89,326, respectively; p < 0.001). The median survival time was 3.7 months in all CC patients, 3.5 months in the PBS group, and 4.0 months in the EBS group. The 1-year, 3-year, and 5-year survival rates were 17.6%, 6.1%, and 3.2% in all CC patients; 16.6%, 4.8%, and 3.2% in the PBS group; and 18.6%, 7.27%, and 3% in the EBS group, respectively. The most important predictor of survival is extrahepatic CC. Medical professionals and healthcare providers should carefully consider the use of EBS for initial treatment of obstructive jaundice in patients with unresectable CC.

[Current situation and perspectives of proton therapy]

Proton beam therapy is indicated as a treatment for some rare tumours and paediatric tumours because the technique allows a good local control with minimal toxicity; the growing number of centres that use proton beam therapy is associated with an increase of dosimetric and clinical data for other malignant tumours as well. This paper reviews potential indications of proton beam therapy. A systematic review on Medline was performed with the following keywords proton beam therapy, cancer, heavy particle, charged particle. No phase III trial has been published using proton beam therapy in comparison with the best photon therapy, but numerous retrospective and dosimetric studies have revealed an advantage of proton beam therapy compared to photons, above all in tumours next to parallel organs at risk (thoracic and abdominal tumours). This could be accompanied with a better safety profile and/or a better tumoural control; numerous phase 0, I, II, III and IV studies are ongoing to examine these hypotheses in more common cancers. Use of proton beam therapy is growing for common cancers within clinical trials but some indications could be applied sooner since in silico analysis showed major advantages with this technique.

Impact of intraluminal brachytherapy on survival outcome for radiation therapy for unresectable biliary tract cancer: a propensity-score matched-pair analysis

PURPOSE

To determine whether adding intraluminal brachytherapy (ILBT) to definitive radiation therapy (RT) for unresectable biliary tract cancer has a positive impact on survival outcome.

METHODS AND MATERIALS

The original cohort comprised 209 patients, including 153 who underwent external beam RT (EBRT) alone and 56 who received both ILBT and EBRT. By matching propensity scores, 56 pairs (112 patients) consisting of 1 patient with and 1 patient without ILBT were selected. They were well balanced in terms of sex, age, performance status, clinical stage, jaundice, and addition of chemotherapy. The impact of ILBT on overall survival (OS), disease-specific survival (DSS), and local control (LC) was investigated.

RESULTS

The 2-year OS rates were 31% for the ILBT+ group and 40% for theILBT- group (P=.862). The 2-year DSS rates were 42% for the ILBT+ group and 41% for the ILBT- group (P=.288). The 2-year LC rates were 65% for the ILBT+ group and 35% for the ILBT- group (P=.094). Three of the 4 sensitivity analyses showed a significantly better LC for the ILBT+ group (P=.010, .025, .049), and another showed a marginally better LC (P=.068), and none of the sensitivity analyses showed any statistically significant differences in OS or DSS.

CONCLUSIONS

In the treatment for unresectable biliary tract cancer, the addition of ILBT to RT has no impact on OS or DSS but is associated with better LC. Therefore, the role of ILBT should be addressed by other measures than survival benefit, for example, by less toxicity, prolonged biliary tract patency decreasing the need for further palliative interventions, or patient quality of life.

Survival outcomes and progonostic factors of extrahepatic cholangiocarcinoma patients following surgical resection: Adjuvant therapy is a favorable prognostic factor

This study was conducted to investigate survival and prognostic factors for extrahepatic cholangiocarcinoma (ECC) following surgical resection and evaluate the effects of postoperative adjuvant therapy (AT) on overall survival (OS). We retrospectively collected clinical and pathological data between March, 2008 and December, 2013. The Kaplan-Meier method and the COX regression model were used to evaluate the OS and prognostic factors of 105 postoperative ECC patients, of whom 32 had received AT. The patients were stratified into seven risk subgroups and the survival rates were compared within each subgroup between patients who received AT and those who did not. The results demonstrated a median OS of 17.6 months, with 1- and 3-year survival rates of 67.9 and 19.5%, respectively, for the entire cohort. On univariate analysis, preoperative cholangitis, non-R0 surgical margins, poor differentiation grade, stage 3/4 and lymphatic metastasis were identified as adverse prognostic factors. AT was not significantly associated with improved OS. However, the subgroup analysis revealed that the effect of AT was significant only in the lymphatic metastasis group (median OS, 21.6 vs. 10.4 months; and 3-year OS, 16.6 vs. 0%, respectively; P=0.02). The survival curves of the AT and non-AT groups were significantly different only for node-positive patients. The COX regression model identified lymphatic metastasis, surgical margins and AT as independent prognostic factors for ECC. A negative resection margin may reduce the mortality rate following surgery by 47%. By contrast, lymph node metastasis was associated with a 2.18-fold higher mortality rate for ECC patients. Postoperative AT contributed to a 0.45-fold mortality rate compared to non-AT ECC patients. Therefore, we concluded that AT is a favorable prognostic factor for ECC patients and it may prolong the survival of patients with lymphatic metastasis. Our data suggest that postoperative AT should be recommended for node-positive ECC patients.

Factors influencing survival outcome for radiotherapy for biliary tract cancer: a multicenter retrospective study

PURPOSE

To seek for the possible factors influencing overall survival (OS) with radiotherapy (RT) for biliary tract cancer.

MATERIALS AND METHODS

Data were collected retrospectively from RT database of 31 institutions in Japan. All patients underwent at least external beam RT. The factors influencing OS were investigated.

RESULTS

Data of 498 patients were analyzed. Median OS of the 212 patients who underwent surgery was significantly better than that of the 286 patients without surgery (31 vs. 15 months, p<0.001). The OS for the R0 or R1 resection group was significantly longer than that for the R2 or non-surgery group, as well as for n0 compared to n1 (all p<0.001). Chemoradiotherapy (CRT), both sequential and concurrent, resulted in a better OS than RT alone for the n1 group (31 vs. 13 months, p<0.001), and marginally better for the R0/R1 group (p=0.065; p=0.054 for concurrent CRT). However, no such benefit was observed for the R2/non-surgical patients. Multivariate analysis identified performance status, clinical stage, and surgery as significant factors.

CONCLUSION

Surgery, especially R0/R1 resection, seemed as the gold standard for treatment of biliary tract cancer including RT, even in the highly heterogeneous population obtained from the multicenter retrospective study. The possibility was shown that CRT yielded better survival benefit especially for n1 patients. We recommend that future prospective trials include an arm of adjuvant CRT at least for n1 and possibly R0/R1 patients.

Clinical outcomes and toxicity of proton beam therapy for advanced cholangiocarcinoma

Background

We examined the efficacy and toxicity of proton beam therapy (PBT) for treating advanced cholangiocarcinoma.

Methods

The clinical data and outcomes of 28 cholangiocarcinoma patients treated with PBT between January 2009 and August 2011 were retrospectively examined. The Kaplan–Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and local control (LC) rates, and the log-rank test to analyze the effects of different clinical and treatment variables on survival. Acute and late toxicities were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0.

Results

The median age of the 17 male and 11 female patients was 71 years (range, 41 to 84 years; intrahepatic/peripheral cholangiocarcinoma, n = 6; hilar cholangiocarcinoma/Klatskin tumor, n = 6; distal extrahepatic cholangiocarcinoma, n = 3; gallbladder cancer, n = 3; local or lymph node recurrence, n = 10; size, 20–175 mm; median 52 mm). The median radiation dose was 68.2 Gy (relative biological effectiveness [RBE]) (range, 50.6 to 80 Gy (RBE)), with delivery of fractions of 2.0 to 3.2 Gy (RBE) daily. The median follow-up duration was 12 months (range, 3 to 29 months). Fifteen patients underwent chemotherapy and 8 patients, palliative biliary stent placement prior to PBT. OS, PFS, and LC rates at 1 year were 49.0%, 29.5%, and 67.7%, respectively. LC was achieved in 6 patients, and was better in patients administered a biologically equivalent dose of 10 (BED10) > 70 Gy compared to those administered < 70 Gy (83.1% vs. 22.2%, respectively, at 1 year). The variables of tumor size and performance status were associated with survival. Late gastrointestinal toxicities grade 2 or greater were observed in 7 patients <12 months after PBT. Cholangitis was observed in 11 patients and 3 patients required stent replacement.

Conclusions

Relatively high LC rates after PBT for advanced cholangiocarcinoma can be achieved by delivery of a BED10 > 70 Gy. Gastrointestinal toxicities, especially those of the duodenum, are dose-limiting toxicities associated with PBT, and early metastatic progression remains a treatment obstacle.

Impact of radiotherapy in the management of locally advanced extrahepatic cholangiocarcinoma

BACKGROUND

Optimal therapy for patients with unresectable locally advanced extrahepatic cholangiocarcinoma (ULAC) remains controversial. We analysed the role of radiotherapy in the management of such tumors.

METHODS

We retrospectively reviewed the charts of patients treated in our institution with conformal-3D external-beam-radiotherapy (EBRT) with or without concurrent chemotherapy.

RESULTS

Thirty patients were included: 24 with a primary tumor (group 1) and 6 with a local relapse (group 2). Toxicity was low. Among 25 patients assessable for EBRT response, we observed 9 complete responses, 4 partial responses, 10 stabilisations, and 2 progressions. The median follow-up was 12 months. Twenty out of 30 patients (66%) experienced a relapse, which was metastatic in 75% of cases in the whole series, 87% in group 1, 60% in group 2 (p = 0.25). Twenty-eight patients (93%) died of relapse or disease complications. Median overall survivals in the whole group and in group 1 or 2 were respectively 12, 11 and 21 months (p = 0.11). The 1-year and 3-year progression-free survivals were respectively 38% and 16% in the whole series; 31% and 11% in group 1, 67% and 33% in group 2 (p = 0.35).

CONCLUSION

EBRT seems efficient to treat ULAC, with acceptable toxicity. For primary disease, the high rate of metastatic relapse suggests to limit EBRT to non-progressive patients after induction chemotherapy.

Nomogram prediction of survival and recurrence in patients with extrahepatic bile duct cancer undergoing curative resection followed by adjuvant chemoradiation therapy

PURPOSE

To develop nomograms for predicting the overall survival (OS) and relapse-free survival (RFS) in patients with extrahepatic bile duct cancer undergoing adjuvant chemoradiation therapy after curative resection.

METHODS AND MATERIALS

From January 1995 through August 2006, a total of 166 consecutive patients underwent curative resection followed by adjuvant chemoradiation therapy. Multivariate analysis using Cox proportional hazards regression was performed, and this Cox model was used as the basis for the nomograms of OS and RFS. We calculated concordance indices of the constructed nomograms and American Joint Committee on Cancer (AJCC) staging system.

RESULTS

The OS rate at 2 years and 5 years was 60.8% and 42.5%, respectively, and the RFS rate at 2 years and 5 years was 52.5% and 38.2%, respectively. The model containing age, sex, tumor location, histologic differentiation, perineural invasion, and lymph node involvement was selected for nomograms. The bootstrap-corrected concordance index of the nomogram for OS and RFS was 0.63 and 0.62, respectively, and that of AJCC staging for OS and RFS was 0.50 and 0.52, respectively.

CONCLUSIONS

We developed nomograms that predicted survival and recurrence better than AJCC staging. With caution, clinicians may use these nomograms as an adjunct to or substitute for AJCC staging for predicting an individual's prognosis and offering tailored adjuvant therapy.

Impact of medical and surgical intervention on survival in patients with cholangiocarcinoma

AIM: To examine surgical and medical outcomes for patients with cholangiocarcinoma using a population-based cancer registry.

METHODS: Using the California Cancer Registry’s Cancer Surveillance Program, patients with intrahepatic cholangiocarcinoma treated in Los Angeles County from 1988 to 2006 were identified and evaluated for clinical and pathologic factors and therapies received (surgery, radiation, and chemotherapy). The surgical cohort was further categorized into three treatment groups: patients who received adjuvant chemotherapy, adjuvant chemoradiation, or underwent surgery alone (no chemotherapy or radiation administered). Survival was assessed by Kaplan-Meier method; and Cox proportional hazard modeling was used in multivariate analysis.

RESULTS: Of 825 patients, 60.2% received no treatment. Of the remaining 328 patients, 18.5% chemotherapy only, 7.4% chemoradiation, and 13.8% underwent surgery. More male patients underwent surgical resection (P = 0.004). Surgical patients were younger than the patients receiving chemotherapy or chemoradiation (P < 0.001). Of the surgical cohort (n = 114), 60.5% underwent surgery alone while 39.5% underwent surgery plus adjuvant therapy (chemotherapy, n = 20; chemoradiation, n = 21) (P < 0.001). Median survival for all patients in the study was 6.6 mo. Median survival was highest for patients who underwent surgery (23 mo), whereas both chemotherapy (9 mo) and chemoradiation (8 mo) alone were each less effective (P < 0.001). By multivariate analysis, extent of disease, receipt of surgery, and administration of chemotherapy (with/without surgery) were independent predictors of overall survival.

CONCLUSION: This study demonstrates that surgery is a critical treatment modality. Multimodality treatment has yet to be standardized, but play a role in optimal therapy for cholangiocarcinoma.

Novel multimodality treatment sequencing for extrahepatic (mid and distal) cholangiocarcinoma

Neoadjuvant chemoradiation has demonstrated significant advantages in the management of pancreatic adenocarcinoma. A similar tumor in a nearby anatomical location is extrahepatic cholangiocarcinoma, which has proven to be largely unresponsive to current forms of therapy. Neoadjuvant therapy for hilar cholangiocarcinoma has been combined with surgical resection and/or liver transplantation with a 25-33 % complete pathological response rate. We propose a wider application of neoadjuvant chemoradiation for patients with distal cholangiocarcinoma and present our rationale for this form of treatment sequencing.

Chemoradiation in patients with unresectable extrahepatic and hilar cholangiocarcinoma or at high risk for disease recurrence after resection : Analysis of treatment efficacy and failure in patients receiving postoperative or primary chemoradiation

BACKGROUND

The purpose of this work was to determine efficacy, toxicity, and patterns of recurrence after concurrent chemoradiation (CRT) in patients with extrahepatic bile duct cancer (EHBDC) and hilar cholangiocarcinoma (Klatskin tumours) in case of incomplete resection or unresectable disease.

PATIENTS AND METHODS

From 2003-2010, 25 patients with nonmetastasized EHBDC and hilar cholangiocarcinoma were treated with radiotherapy and CRT at our institution in an postoperative setting (10 patients, 9 patients with R1 resections) or in case of unresectable disease (15 patients). Median age was 63 years (range 38-80 years) and there were 20 men and 5 women. Median applied dose was 45 Gy in both patient groups.

RESULTS

Patients at high risk (9 times R1 resection, 1 pathologically confirmed lymphangiosis) for tumour recurrence after curative surgery had a median time to disease progression of 8.7 months and an estimated mean overall survival of 23.2 months (6 of 10 patients are still under observation). Patients undergoing combined chemoradiation in case of unresectable primary tumours are still having a poor prognosis with a progression-free survival of 7.1 months and a median overall survival of 12.0 months. The main site of progression was systemic (liver, peritoneum) in both patient groups.

CONCLUSION

Chemoradiation with gemcitabine is safe and can be applied safely in either patients with EHBDC or Klatskin tumours at high risk for tumour recurrence after resection and patients with unresectable tumours. Escalation of systemic and local treatment should be investigated in future clinical trials.

Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer

PURPOSE

Although adjuvant chemoradiotherapy for resected gallbladder cancer may improve survival for some patients, identifying which patients will benefit remains challenging because of the rarity of this disease. The specific aim of this study was to create a decision aid to help make individualized estimates of the potential survival benefit of adjuvant chemoradiotherapy for patients with resected gallbladder cancer.

METHODS

Patients with resected gallbladder cancer were selected from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database who were diagnosed between 1995 and 2005. Covariates included age, race, sex, stage, and receipt of adjuvant chemotherapy or chemoradiotherapy (CRT). Propensity score weighting was used to balance covariates between treated and untreated groups. Several types of multivariate survival regression models were constructed and compared, including Cox proportional hazards, Weibull, exponential, log-logistic, and lognormal models. Model performance was compared using the Akaike information criterion. The primary end point was overall survival with or without adjuvant chemotherapy or CRT.

RESULTS

A total of 1,137 patients met the inclusion criteria for the study. The lognormal survival model showed the best performance. A Web browser-based nomogram was built from this model to make individualized estimates of survival. The model predicts that certain subsets of patients with at least T2 or N1 disease will gain a survival benefit from adjuvant CRT, and the magnitude of benefit for an individual patient can vary.

CONCLUSION

A nomogram built from a parametric survival model from the SEER-Medicare database can be used as a decision aid to predict which gallbladder patients may benefit from adjuvant CRT.

Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma

PURPOSE

this report aims to provide an overview on radiotherapy and chemotherapy in extrahepatic biliary duct carcinoma (BDC).

PATIENTS AND METHODS

a PubMed research identified clinical trials in BDC through April 1, 2010 including randomised controlled trials, SEER analyses and retrospective trials. Additionally, publications on the technical progress of radiotherapy in or close to the liver were analysed.

RESULTS

most patients with cholangiocarcinoma present with unresectable disease (80-90%), and more than half of the resected patients relapse within 1 year. Adjuvant and palliative treatment options need to be chosen carefully since 50% of the patients are older than 70 years at diagnosis. Adjuvant radiotherapy or chemotherapy after complete resection (R0) has not convincingly shown a prolongation of survival but radiotherapy did after R1 resection. However, data suggest that liver transplantation could offer long-term survival in selected patients when combined with neoadjuvant chemoradiotherapy in patients with marginally resectable disease. For patients with unresectable biliary tract carcinoma (BTC), palliative stenting was previously the treatment of choice. But recent SEER analyses show that radiotherapy prolongs survival, relieves symptoms and contributes to biliary decompression and should be regarded as the new standard. Novel technical advances in radiotherapy may allow for dose-escalation and could significantly improve outcome for patients with cholangiocarcinoma.

CONCLUSION

both the literature and recent technical progress corroborate the role of radiotherapy in BDC offering chances for novel clinical trials. Progress is less pronounced in chemotherapy.

Parametric survival models for predicting the benefit of adjuvant chemoradiotherapy in gallbladder cancer

The Cox proportional hazards model is the most commonly used survival model in oncology; however, this semi-parametric model may not be the most appropriate survival model when the proportionality assumption does not hold. In this study, we consider the use of several types of accelerated failure time parametric survival techniques for modeling the benefit of adjuvant chemoradiotherapy for gallbladder cancer. In comparing the Weibull, exponential, log-logistic, and log-normal models, we found that the log-normal had the most favorable Akaike Information Criterion, and additional analyses of this model indicated that our gallbladder cancer dataset exhibited a good fit with the log-normal cumulative hazard function. This log-normal survival model can be used to help predict which patients will benefit from adjuvant chemoradiotherapy.