Multidisciplinary treatment of biliary tract cancers

Phase I study of neoadjuvant S-1 plus cisplatin with concurrent radiation for biliary tract cancer (Tokyo Study Group for Biliary Cancer: TOSBIC02)

Aim

Neoadjuvant chemoradiotherapy may improve survival in patients with advanced cholangiocarcinoma. This Phase I study aimed to determine the recommended dose of neoadjuvant chemoradiotherapy and decide whether to move to a Phase II study.

Methods

Patients diagnosed with resectable stage II-IVa cholangiocarcinoma were administered cisplatin (40 [level 0], 50 [level 1 as starting dose], or 60 [level 2] mg/m2), 80 mg/m2 of S-1, and 50.4 Gy of external beam radiation. The recommended dose was defined as a dose one-step lower than the maximum-tolerated dose, which was defined when dose-limiting toxicity was observed in three or more of the six patients.

Results

Twelve patients were eligible from November 2012 to May 2016. Ten patients had perihilar cholangiocarcinoma and two patients had distal cholangiocarcinoma. Dose-limiting toxicity was observed in one of the first six patients at level 1 and two of the next six patients at level 2; thus, the maximum-tolerated dose was not determined even at level 2 and the recommended dose was determined as level 2. Four patients had partial response, four patients had stable disease, and two patients had progression of disease because of liver metastases. Finally, nine patients underwent radical surgery and seven cases achieved R0 resection. However, five cases suffered biliary leakage and one suffered intrahospital death due to rupture of the hepatic artery.

Conclusion

We determined the recommended dose of neoadjuvant chemoradiotherapy for resectable cholangiocarcinoma. However, we terminated the trial due to a high incidence of morbidity and unexpected mortality.

Adjuvant radiotherapy improves long-term survival after resection for gallbladder cancer A population-based cohort study

BACKGROUND

Data supporting routine use of adjuvant radiotherapy (RT) compared to without RT (noRT) for gallbladder cancer (GBC) is unclear. This study aimed to determine whether RT improves long-term survival following resection for GBC.

METHODS

Patients receiving resection for GBC followed by RT from 2004 to 2016 were identified from the National Cancer Database (NCDB). Patients with survival <6 months were excluded to account for immortal time bias. Propensity score matching (PSM) and Cox regression was performed to account for selection bias and analyze impact of RT on overall survival.

RESULTS

Of 7514 (77%) noRT and 2261 (23%) RT, 2067 noRT and 2067 RT patients remained after PSM. After matching, RT was associated with improved survival (median: 26.2 vs 21.5 months, p < 0.001), which remained after multivariable adjustment (HR: 0.82, CI_95%: 0.76-0.89, p < 0.001). On multivariable interaction analyses, this benefit persisted irrespective of nodal status: N0 (HR: 0.84, CI_95%: 0.77-0.93), N1 (HR: 0.77, CI_95%: 0.68-0.88), N2/N3 (HR: 0.56, CI_95%: 0.35-0.91), margin status: R0 (HR: 0.85, CI_95%: 0.78-0.93), R1 (HR: 0.78, CI_95%: 0.68-0.88) and use of adjuvant chemotherapy (AC) (HR: 0.67, CI_95%: 0.57-0.79). Benefit with RT were also seen in patients with T2 - T4 disease and in patients undergoing simple and extended cholecystectomy.

CONCLUSION

RT following resection was associated with improved survival in this study, even in margin-negative and node-negative disease. These findings may suggest addition of RT into multimodality therapy for GBC.

Current standards and future perspectives in adjuvant treatment for biliary tract cancers

Biliary tract cancer, including cholangiocarcinoma (CCA) and gallbladder cancer (GBC) are rare tumours with a rising incidence. Prognosis is poor, since most patients are diagnosed with advanced disease. Only ~20% of patients are diagnosed with early-stage disease, suitable for curative surgery. Despite surgery performed with potentially-curative intent, relapse rates are high, with around 60-70% of patients expected to have disease recurrence. Most relapses occur in the form of distant metastases, with a predominance of liver spread. In view of high tumour recurrence, adjuvant strategies have been explored for many years, in the form of radiotherapy, chemo-radiotherapy and chemotherapy. Historically, few randomised trials were available, which included a variety of additional tumours (e.g. pancreatic and ampullary tumours); most evidence relied on phase II and retrospective studies, with no high-quality evidence available to define the real benefit derived from adjuvant strategies. Since 2017, three randomised phase III clinical trials have been reported; all recruited patients with resected biliary tract cancer (CCA and GBC) who were randomised to observation alone, or chemotherapy in the form of gemcitabine (BCAT study; included patients diagnosed with extrahepatic CCA only), gemcitabine and oxaliplatin (PRODIGE-12/ACCORD-18; included patients diagnosed with CCA and GBC) or capecitabine (BILCAP; included patients diagnosed with CCA and GBC). While gemcitabine-based chemotherapy failed to show an impact on patient outcome (relapse-free survival (RFS) or overall survival (OS)), the BILCAP study showed a benefit from adjuvant capecitabine in terms of OS (pre-planned sensitivity analysis in the intention-to-treat population and in the per-protocol analysis), with confirmed benefit in terms of RFS. Based on the BILCAP trial, international guidelines recommend adjuvant capecitabine for a period of six months following potentially curative resection of CCA as the current standard of care for resected CCA and GBC. However, BILCAP failed to show OS benefit in the intention-to-treat (non-sensitivity analysis) population (primary end-point), and this finding, as well as some inconsistencies between studies has been criticised and has led to confusion in the biliary tract cancer medical community. This review summarises the adjuvant field in biliary tract cancer, with evidence before and after 2017, and comparison between the latest randomised phase III studies. Potential explanations are presented for differential findings, and future steps are explored.

Outcomes of adjuvant treatments for resectable intrahepatic cholangiocarcinoma: Chemotherapy alone, sequential chemoradiotherapy, or concurrent chemoradiotherapy

BACKGROUND

Prospective randomized trials have not been used to evaluate the efficacy of adjuvant therapies after intrahepatic cholangiocarcinoma (ICC) resection.

METHODS

We analyzed data from the Taiwan Cancer Registry database of ICC patients receiving resection. To compare outcomes, patients with ICC were enrolled and categorized into the following adjuvant treatment modality groups: group 1, concurrent chemoradiotherapy (CCRT); group 2, sequential chemotherapy (CT) and radiotherapy (RT); and group 3, CT alone.

RESULTS

We enrolled 599 patients with resectable ICC who received surgery without distant metastasis. Of these patients, 174 received adjuvant CCRT (group 1), 146 received adjuvant sequential CT and RT (group 2), and 279 received adjuvant CT alone (group 3). Multivariate Cox regression analysis indicated that pathologic stage and positive margin were significantly poor independent predictors. After adjustment for confounders, adjusted hazard ratios (95% confidence intervals) for overall mortality at advanced pathologic stages III and IV were 0.55 (0.41-0.74) and 0.92 (0.70-1.33) in groups 1 and 2, respectively, compared with group 3.

CONCLUSIONS

Adjuvant CCRT improved survival in resected ICC with advanced pathologic stages or a positive margin in early pathologic stages compared with adjuvant CT alone or adjuvant sequential CT and RT.

Salvage radiotherapy for locoregionally recurrent extrahepatic bile duct cancer after radical surgery

OBJECTIVE

This study evaluated the outcome of salvage radiotherapy for locoregionally recurrent extrahepatic bile duct cancer.

METHODS

We performed a retrospective review of 23 extrahepatic bile duct cancer patients who underwent radiotherapy with or without concomitant chemotherapy for isolated locoregional recurrence after radical surgery between August 2001 and September 2013. The median disease-free interval was 11.8 months. Salvage radiotherapy was delivered to the recurrent tumour with or without initial operation bed up to a median dose of 54 Gy (range, 45-60). 18 patients received concomitant chemotherapy.

RESULTS

The median follow-up period was 14.2 months for all patients, and 48.8 months for survivors. The median overall survival and progression-free survival (PFS) were 18.4 (range, 4.4-114.6) and 15.5 months (range, 1.6-114.6), respectively. On multivariate analysis, the use of concomitant chemotherapy was a favourable prognostic factor for PFS (p = 0.027), and prolonged disease-free interval (≥1 year) was associated with a significantly poor overall survival (p = 0.047). Grade 3 or higher toxicities did not occur in follow-up period.

CONCLUSION

Salvage radiotherapy showed promising survival outcomes in locoregional recurrence of extrahepatic bile duct cancer. Our results indicated that concomitant chemotherapy was associated with improved PFS. Concurrent chemoradiotherapy can be a viable salvage treatment option in selected patients. Advances in knowledge: Locoregional recurrence is the most common pattern of failure after radical resection in extrahepatic bile duct cancer. In this study, salvage radiotherapy showed favourable survival outcomes without severe complications in locoregionally recurrent extrahepatic bile duct cancer patients.

A phase II study of adjuvant gemcitabine plus docetaxel followed by concurrent chemoradation in resected pancreaticobiliary carcinoma

OBJECTIVES

Adjuvant gemcitabine with or without chemoradiation is a standard therapeutic option for patients with resected pancreatic cancer. The feasibility and toxicity of gemcitabine with docetaxel before and after 5-fluorouracil (5FU)-based chemoradiation in the adjuvant pancreatic and biliary cancer setting were investigated.

METHODS

After a curative-intent resection, eligible patients with pancreaticobiliary cancers were treated with two cycles of gemcitabine and docetaxel followed by 5FU-based chemoradiation. Four weeks after completing chemoradiation, two cycles of gemcitabine and docetaxel were administered. The primary endpoint was the incidence of severe toxicities. Secondary endpoints included disease-free survival (DFS) and overall survival (OS).

RESULTS

Fifty patients with pancreaticobiliary cancers were enrolled. Twenty-nine patients had pancreatic cancer whereas 21 patients had biliary tract or ampullary cancers. There was one death as a result of pneumonia, and 15% of patients experienced grade 3 or greater non-haematological toxicities. The median DFS and OS for patients with pancreatic cancer were 9.6 and 17 months, respectively, and for those with resected biliary tract cancer were 12 and 23 months, respectively.

CONCLUSIONS

This combination of gemcitabine and docetaxel with chemoradiation is feasible and tolerable in the adjuvant setting. Future studies utilizing a different gemcitabine/taxane combination and schedule may be appropriate in the adjuvant treatment of both pancreatic cancer and biliary tumours.

Chemotherapy and targeted therapy for gall bladder cancer

Gall bladder cancer is a common cancer in the Ganges belt of North-eastern India. In view of incidental diagnosis of gall bladder cancer by physicians and surgeons, the treatment is not optimised. Most patients present in advanced stages and surgery remains the only option to cure. This review highlights the current evidence in advances in systemic therapy of gall bladder cancer.

Impact of adjuvant external beam radiotherapy on survival in surgically resected gallbladder adenocarcinoma: a propensity score-matched Surveillance, Epidemiology, and End Results analysis

BACKGROUND

We sought to define the utilization and effect of adjuvant external-beam radiotherapy (XRT) on patients having undergone curative-intent resection for gallbladder cancer (GBC).

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 5,011 patients with GBC who underwent resection between 1988 and 2009. The impact of XRT on survival was analyzed by the use of propensity-score matching by comparing clinicopathologic factors between patients who received resection only versus resection plus XRT.

RESULTS

Median age was 72 years, and most patients were female (73.4%); 66.2% patients had intermediate to poorly differentiated tumors, and 19.1% had lymph node metastasis. The majority (75.0%) had "localized" disease by Surveillance, Epidemiology, and End Results classification. A total of 899 patients (17.9%) received XRT whereas 4,112 patients did not. Factors associated with receipt of XRT were younger age (odds ratio [OR] 5.33), tumor extension beyond the serosa (OR 1.55), intermediate- to poorly differentiated tumors (OR 1.56), and lymph node metastasis (OR 2.59) (all P < .05). Median and 1-year survival were 15 months and 59.0%, respectively. On propensity-matched multivariate model, despite having more advanced tumors, XRT was independently associated with better long-term survival at 1 year (hazard ratio 0.45; P < .001), but not 5 years (hazard ratio 1.06; P = .50).

CONCLUSION

A total of 18% of patients with GBC received XRT after curative intent surgery. The use of adjuvant XRT was associated with a short-term survival benefit, but the benefit dissipated over time.

Current state of nonsurgical therapies for cholangiocarcinoma

Cholangiocarcinomas (CCCs) are rare tumors that are derived from the epithelial cell lining of the bile ducts. They can be classified as intrahepatic, extrahepatic-perihilar and extrahepatic-distal tumors. The prognosis of CCCs is poor as, in many cases, they are diagnosed at advanced stages, at which point curative surgical resection is not possible. Furthermore, most patients will experience a tumor recurrence despite initial complete CCC resection. Therefore, alternative/additional therapeutic strategies are needed to improve tumor- and recurrence-free survival after surgery as well as tumor control in patients with advanced disease. In clinical practice, apart from systemic chemotherapies for the therapeutic management of CCCs, locoregional as well as multimodal strategies are available, including external and internal radiation therapies. This review focuses on the currently available nonsurgical therapies for patients with CCCs, alone or in combination with other modalities, and on evolving therapeutic concepts that are being explored in clinical studies.

Gemcitabine with carboplatin for advanced biliary tract cancers: a phase II single institution study

BACKGROUND

Only recently has a standard chemotherapy regimen, gemcitabine plus cisplatin, been established for advanced biliary tract cancers (BTCs) based on a phase III randomized study. The aim of this phase II single-institution trial was to assess the efficacy and safety of gemcitabine combined with carboplatin in the first-line treatment of patients with advanced BTCs.

METHODS

Patients with histologically proven BTCs, including cholangiocarcinoma or gallbladder and ampullary carcinomas, were treated with a maximum of nine cycles of intravenous (i.v.) gemcitabine at 1000 mg/m(2) over 30 min on days 1 and 8 with i.v. carboplatin dosed at an area-under-the-curve (AUC) of 5 over 60 min on day 1 of a 21-day cycle.

RESULTS

A total of 48 patients with advanced BTCs (35 cholangiocarcinoma, 12 gallbladder and 1 ampullary cancer) were enrolled. A median of four cycles were administered (range: 1-9). The overall response rate for evaluable patients was 31.1%. Median progression-free survival, overall survival and 6-month survival rates are 7.8 months, 10.6 months and 85.4%, respectively. The most common grade 3-4 toxicities include neutropenia and thrombocytopenia. Grade 3 or 4 non-haematological toxicities were rare.

CONCLUSIONS

Gemcitabine combined with carboplatin has activity against advanced BTCs. Our results are comparable to other gemcitabine-platinum or gemcitabine-fluoropyrimidine combinations in advanced BTCs.

Current management of gallbladder carcinoma

Gallbladder cancer (GBC) represents the most common and aggressive type among the biliary tree cancers (BTCs). Complete surgical resection offers the only chance for cure; however, only 10% of patients with GBC present with early-stage disease and are considered surgical candidates. Among those patients who do undergo "curative" resection, recurrence rates are high. There are no established adjuvant treatments in this setting. Patients with unresectable or metastatic GBC have a poor prognosis. There has been a paucity of randomized phase III data in this field. A recent report demonstrated longer overall survival with gemcitabine in combination with cisplatin than with gemcitabine alone in patients with advanced or metastatic BTCs. Molecularly targeted agents are under development. In this review, we attempt to discuss the current status and key issues involved in the management of GBC.

Adjuvant concurrent chemoradiation therapy (CCRT) alone versus CCRT followed by adjuvant chemotherapy: which is better in patients with radically resected extrahepatic biliary tract cancer?: a non-randomized, single center study

Background

There is currently no standard adjuvant therapy for patients with curatively resected extrahepatic biliary tract cancer (EHBTC). The aim of this study was to analyze the clinical features and outcomes between patients undergoing adjuvant concurrent chemoradiation therapy (CCRT) alone and those undergoing CCRT followed by adjuvant chemotherapy after curative resection.

Methods

We included 120 patients with EHBTC who underwent radical resection and then received adjuvant CCRT with or without further adjuvant chemotherapy between 2000 and 2006 at Seoul National University Hospital.

Results

Out of 120 patients, 30 received CCRT alone, and 90 received CCRT followed by adjuvant chemotherapy. Baseline characteristics were comparable between the two groups. Three-year disease-free survival (DFS) rates for CCRT alone and CCRT followed by adjuvant chemotherapy were 26.6% and 45.2% (p = 0.04), respectively, and 3-year overall survival (OS) rates were 30.8% and 62.6% (p < 0.01), respectively. CCRT followed by adjuvant chemotherapy showed longer survival than did CCRT alone, especially in R1 resection (microscopically positive margins) or negative lymph node.

Conclusion

Adjuvant CCRT followed by adjuvant chemotherapy prolonged DFS and OS, compared with CCRT alone in patients with curatively resected EHBTC. Adjuvant chemotherapy deserves to consider after adjuvant CCRT. In the future, a randomized prospective study will be needed, with the objective of investigating the role of adjuvant chemotherapy.

Extrahepatic bile duct adenocarcinoma: patients at high-risk for local recurrence treated with surgery and adjuvant chemoradiation have an equivalent overall survival to patients with standard-risk treated with surgery alone

BACKGROUND

Patients with resected extrahepatic bile duct adenocarcinoma who have microscopically positive resection margins and/or pathologic locoregional nodal involvement (R1pN1) have a high-risk of locoregional recurrence, and therefore, we advocate the use of adjuvant chemoradiation. To evaluate the safety and effectiveness of this treatment, we compared survival and side effects outcomes between such patients and patients with negative resection margins and pathologically negative nodes (R0pN0) who did not receive adjuvant treatment.

METHODS

Between 1984 and 2005, 65 patients were treated with curative-intended resection for extrahepatic bile duct adenocarcinoma. Patients with tumors arising in the gallbladder and periampullary region were excluded. Pathology and diagnostic images were centrally reviewed. Overall survival and locoregional recurrence outcomes for patients with standard-risk R0pN0 (surgery alone, or S group, n = 23) were compared with those of patients with high locoregional recurrence risk, R1 and/or pN1 (R1pN1) status who received adjuvant chemoradiation (S-CRT group, n = 42).

RESULTS

The median follow-up for the entire group was 31 months. Patients in the S-CRT and S groups had a similar 5-year overall survival (36% vs. 42%, P = .6) and locoregional recurrence (5-year rate: 38% vs. 37%, P = .13). In the S-CRT group, three patients (7%) experienced an acute (grade 3 or more) side effect.

CONCLUSIONS

Our finding of a lack of a survival difference between the S and S-CRT groups suggests that for patients with extrahepatic bile duct adenocarcinoma at high risk for locoregional recurrence (i.e., R1 resection or pN1 disease), adjuvant chemoradiation provides an equivalent overall survival despite of these worse prognostic features.

Adjuvant radiation therapy is associated with improved survival for gallbladder carcinoma with regional metastatic disease

BACKGROUND

Gallbladder carcinoma is a rare malignancy and is associated with dismal outcomes. The aim of this study was to better define the role of adjuvant radiation therapy in the management of gallbladder carcinoma.

METHODS

The Surveillance, Epidemiological, and End Results (SEER) survey from the National Cancer Institute was queried from 1992 to 2002. Retrospective analysis was done. The end-point of the study was overall survival.

RESULTS

There were a total of 3,187 cases of gallbladder carcinoma in the registry from 1992 to 2002. Of the surgical group, 35% were stage I, 36% were stage II, 6% were stage III, and 21% were stage IV. Adjuvant radiation was used in 17% of the cases. The median survival for those patients receiving adjuvant radiation therapy was 14 months compared to an 8 months median survival for those treated without adjuvant radiation therapy (P < or = 0.001). The survival benefit associated with radiation use was only presenting those patients with regional spread (P = 0.0001) and tumors infiltrating the liver (P = 0.011).

CONCLUSION

The use of adjuvant radiation therapy is associated with improved survival in patients with locally advanced gallbladder cancer or gallbladder cancer with regional disease.

Role of postoperative radiotherapy in the management of extrahepatic bile duct cancer

PURPOSE

To analyze the outcome of postoperative radiotherapy (RT) or chemoradiation for patients with extrahepatic bile duct cancer who had undergone either curative or palliative surgery, and to identify the prognostic factors for these patients.

METHODS AND MATERIALS

Between March 1982 and December 1994, 91 patients with extrahepatic bile duct cancer underwent RT at the Department of Therapeutic Radiology, Seoul National University Hospital. Of these patients, 84 were included in this retrospective study. The male/female ratio was 3.7:1 (66 men and 18 women). The median age of the patients was 58 years (range 33-76). Gross total surgical resection was performed in 72 patients, with pathologically negative margins in 47 and microscopically positive margins in 25. Twelve patients underwent surgical exploration and biopsy or subtotal resection with palliative bypass procedures. All the patients received >40 Gy of external beam RT after surgery. Concurrent 5-fluorouracil was administered during external beam RT in 71 patients, and maintenance chemotherapy was performed in 61 patients after RT completion. The minimal follow-up of the survivors was 14 months, and the median follow-up period for all the patients was 23 months (range 2-75).

RESULTS

The overall 2- and 5-year survival rate was 52% and 31%, respectively. The 2- and 5-year disease-free survival rate was 48% and 26%, respectively. On univariate analysis using the Kaplan-Meier product limit method, the use of chemotherapy, performance status, N stage, size of residual tumor, stage, and tumor location were significant prognostic factors. However, on multivariate analysis using Cox's proportional hazard model, N stage (N0 vs. N1 and N2, p = 0.02) was the only significant prognostic factor.

CONCLUSION

Long-term survival can be expected in patients with extrahepatic bile duct cancer who undergo radical surgery and postoperative chemoradiation. Regional lymph node metastasis is a poor prognostic factor for these patients.

Palliative and postoperative radiotherapy in biliary tract cancer

Local failure is the primary limitation for cure in patients with BTC. whether or not they have been resected. The use of radiotherapy with or without chemotherapy in the postoperative setting is controversial, but some studies have reported improvement in 5-year survival. In patients with unresectable BTC, EBRT offers effective palliation of symptomatic disease and has resulted in improved median and long-term survival in a small number of patients in most studies. Novel approaches, including neoadjuvant chemoradiotherapy combined with OLT, and escalated conformal irradiation, seem to be promising and warrant further investigation.

Improved survival in resected biliary malignancies

BACKGROUND

For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor. Now, the surgical goal is to achieve negative microscopic margins even if a major hepatic resection is required. Similarly, chemotherapy or radiation was frequently given in isolation, but chemoradiation has become the standard. Therefore, the aim of this analysis was to determine whether survival has improved with better staging, active stent management, more aggressive surgery, and chemoradiation.

METHODS

From 1990 through 2001, 140 patients with biliary malignancies were treated at the Medical College of Wisconsin. One hundred eleven malignancies were cholangiocarcinomas (intrahepatic, 22%; perihilar, 65%; and distal, 13%), and 29 were gallbladder (GB) cancers. Eighty-six of the 140 patients (61%) underwent exploration (intrahepatic, 58%; perihilar, 57%; distal, 67%, and GB, 72%). Forty-four of these 86 patients (51%) underwent resection (intrahepatic, 64%; perihilar, 41%; distal, 70%; and GB, 52%). Chemoradiation with confocal radiation, 5-fluorouracil, and gemcitabine was used more frequently in the patients resected since 1998.

RESULTS

Thirty-day operative mortality was 4%. In the resected patients (n = 44) the 5-year actuarial survival was 31% and the median survival was 27.8 months. Patients resected between 1998 and 2001 (n = 25) had a median survival longer than 44 months with a 3-year actuarial survival of 70% as compared to patients resected between 1990 and 1997 (n = 19), who had a median survival of 13 months and a 3-year actuarial survival of 21% (P <.01).

CONCLUSIONS

These data suggest that (1) approximately one third of patients with biliary malignancies have resectable disease and (2) surgery in carefully selected patients with adjuvant chemoradiation has improved survival in resected patients. We suspect that a combination of improved staging, active biliary stenting, safe but extensive surgery to obtain negative margins, and newer techniques for chemoradiation have resulted in improved outcomes for patients with biliary malignancies.

Limitations of conventional doses of chemoradiation for unresectable biliary cancer

PURPOSE

To determine, in a retrospective review, the limitations of definitive chemoradiation in the treatment of patients with unresectable extrahepatic cholangiocarcinoma and generate testable hypotheses for future prospective clinical trials.

METHODS AND MATERIALS

Between 1957 and 2000, 52 patients with localized, unresectable cholangiocarcinoma were treated with radiotherapy (RT) with or without concurrent chemotherapy. Unresectable disease was defined, by evidence on imaging studies or at surgical exploration, as localized tumor abutting or involving the main portal vein, tumor involvement of secondary biliary radicals, or evidence of nodal metastases. Patients were grouped according to the RT dose: 27 patients received a total dose of 30 Gy (Group 1), 14 patients received 36-50.4 Gy (Group 2), and 11 patients received 54-85 Gy (Group 3). 192Ir intracavitary boosts (median 20 Gy) were delivered in 3 patients, and an intraoperative boost (20 Gy) was used in 1 patient. Of the 52 patients, 38 (73%) received concomitant protracted venous infusion of 5-fluorouracil (200-300 mg/m2 daily, Monday through Friday). Kaplan-Meier analysis was used to calculate the actuarial 1-year and median overall survival (OS), radiographic local progression, symptomatic progression, and distant failure. Treatment-related variables and prognostic factors were evaluated using the log-rank test.

RESULTS

The first site of disease progression was local in 72% of cases. The actuarial local progression rate at 12 months for all patients was 59%. The median time to radiographic local progression was 9, 11, and 15 months in Groups 1, 2, and 3, respectively (p = 0.48). Fifteen percent of all patients developed metastatic disease (1-year OS rate 18%). The median survival rate for all patients was 10 months (1-year OS rate 44%). The RT dose, use of concurrent chemotherapy, histologic grade, initial extent of liver involvement, and extent of vascular involvement had no influence on radiographic local progression or OS. Grade 3 or greater toxicity was similar in all dose groups (22% vs. 14% vs. 27%, p = 0.718).

CONCLUSION

The primary limitation of definitive chemoradiation was local progression. Although the small patient numbers limited the statistical power of this study, a suggestion of improved local control was found with the use of higher RT doses. To address this pattern of failure, future prospective investigation using high-dose conformal RT with novel cytotoxic and/or biologic agents with radiosensitizing properties is warranted.

Location, not Staging, of Cholangiocarcinoma Determines the Role for Adjuvant Chemoradiation Therapy

The role of adjuvant chemoradiation therapy (CT/XRT) in the treatment of cholangiocarcinoma is controversial. We undertook this study to determine whether CT/XRT is appropriate after resection of cholangiocarcinomas. One hundred ninety-two patients with cholangiocarcinomas were treated from 1988 to 1999. After resection, patients were assigned a stage (TNM) and were stratified by location of the tumor as intrahepatic, perihilar, and distal tumors. Data are presented as mean ± standard deviation. Of 192 patients 92 (48%) underwent resections of cholangiocarcinomas. Thirty-four patients had liver resections, 25 had bile duct resections, and 33 underwent pancreaticoduodenectomies. Thirty-four patients had adjuvant CT/XRT, three had adjuvant chemotherapy, four had neoadjuvant CT/XRT, and 50 had no radiation or chemotherapy. Mean survival of resected patients with adjuvant CT/XRT was 42 ± 37.0 months and without CT/XRT it was 29 ± 24.5 months ( P = 0.07). Mean survival of patients with distal tumors receiving or not receiving CT/XRT was 41 ± 21.8 versus 25 ± 20.1 months, respectively, ( P = 0.04). Adjuvant chemoradiation improves survival after resection for cholangiocarcinoma ( P = 0.07) particularly in patients undergoing resection for distal tumors ( P = 0.04). Benefits of adjuvant CT/XRT are apparent when stratified by location of cholangiocarcinomas rather than staging.

Cholangiocarcinoma

Despite overall advances in the ability to diagnose and treat patients with cholangiocarcinoma, the prognosis for patients with this malignancy remains poor. Further improvements in the survival of patients with cholangiocarcinoma will come with the early diagnosis of these lesions. New molecular techniques should improve the ability to screen high-risk patients, such as those with primary sclerosing cholangitis, hepatolithiasis, choledochal cysts, and ulcerative colitis. Improvements in imaging will continue, and spiral CT scanning, duplex ultrasonography, MR imaging and, perhaps, PET scans will improve the ability to stage patients with cholangiocarcinoma noninvasively. Complete surgical resection remains the only curative treatment for malignancies of the biliary tract. Aggressive surgical approaches are likely to continue, and the challenge remains in being able to perform these procedures safely in jaundiced and sometimes septic patients. For patients with unresectable lesions, the optimal form of palliation, whether surgical or nonsurgical, remains to be defined. Finally, multicenter, prospective, randomized trials of chemoradiation need to be performed to delineate an effective adjuvant therapy more precisely, and to improve the overall prognosis of patients with cholangiocarcinoma.

Combined modality treatment in unresectable extrahepatic biliary carcinoma

PURPOSE

Cancers of the extrahepatic biliary tract are rare. Surgical resection is considered the standard treatment, but is rarely feasible. Several reports of combined modality therapy, including external beam radiation, often combined with chemotherapy and intraluminal brachytherapy, have been published. The purpose of this study was to evaluate the effect of chemoradiation plus intraluminal brachytherapy on response, local control, survival, and symptom relief in patients with unresectable or residual extrahepatic biliary carcinoma.

METHODS AND MATERIALS

From February 1991 to December 1997, 20 patients (14 male, 6 female; mean age 61 +/- 12 years; median follow-up 71 months) with unresectable (16 patients) or residual (4 patients), nonmetastatic extrahepatic bile tumors (common bile duct, 8; gallbladder, 1; Klatskin, 11) received external beam radiation (39.6-50.4 Gy); in 19 patients, 5-fluorouracil (96-h continuous infusion, days 1-4 at 1,000 mg/m(2)/day) was also administered. Twelve patients received a boost by intraluminal brachytherapy using (192)Ir wires of 30-50 Gy, prescribed 1 cm from the source axis.

RESULTS

During external beam radiotherapy, 8 patients (40%) developed grade 1-2 gastrointestinal toxicity. Four patients treated with external-beam plus intraluminal brachytherapy had a clinical response (2 partial, 2 complete) after treatment. For the total patient group, the median survival and time to local progression was 21.2 and 33.1 months, respectively. Distant metastasis occurred in 10 (50%) patients. Two patients who received external beam radiation plus intraluminal brachytherapy developed late duodenal ulceration. Two patients with unresectable disease survived more than 5 years.

CONCLUSION

Our data suggest that chemoradiation plus intraluminal brachytherapy was relatively well-tolerated, and resulted in reasonable local control and median survival. Further follow-up and additional research is needed to determine the ultimate efficacy of this regimen. New chemoradiation combinations and/or new treatment strategies (neoadjuvant chemoradiation) may contribute, in the future, to improve these results.

Carcinoma of the gall-bladder

Carcinoma of the gall-bladder remains the fifth commonest gastrointestinal malignancy. Its associations, predisposing factors and epidemiology worldwide are reviewed in this article. The clinical presentation of carcinoma of the gall-bladder is frequently late, which accounts for the poor prognosis: this is also discussed. The use of relevant imaging techniques and aggressive management offer an improved outlook. These important aspects and others, such as the use of frozen section histology, the risks of trocar seeding and inadequate resection are mentioned.

Risk factors for biliary tract cancers

OBJECTIVE

Little is known regarding risk factors for biliary tract cancer, i.e., gallbladder carcinoma and extrahepatic bile duct carcinoma. This is the first case-control study conducted in the U.S. regarding risk factors for these cancers.

METHODS

In this hospital-based case-control study, we reviewed the medical records of 69 patients with primary biliary tract cancer who were admitted to Columbia-Presbyterian Medical Center for surgery between January 1, 1980, and April 4, 1994, and of 138 controls, consisting of patients admitted for surgery for benign conditions.

RESULTS

We found a significant association between cholelithiasis and biliary tract cancers (odds ratio, 19.5; 95% confidence interval, 6.4-59.4). Risk factors associated with gallbladder cancer included female gender, age, cigarette smoking, and postmenopausal status in women. Risk factors associated with extrahepatic bile duct cancer included history of cholecystectomy and hysterectomy in women.

CONCLUSION

The risk factors for biliary tract cancers that have been identified in our study delineate a high-risk population, which in the future may be targeted for preventive measures.

Carcinoma of the extrahepatic biliary tract: surgery and radiotherapy for curative and palliative intent

Forty-seven patients were treated for carcinoma of the extrahepatic biliary tract between 1962 and 1993: 17 by surgery alone, 20 by surgery and postoperative radiotherapy, and 10 with radiotherapy alone. Initial operations included gross total resection (17 patients), simple cholecystectomy (6 patients), subtotal resection (11 patients), biopsy (3 patients), and percutaneous decompression (10 patients). External-beam radiotherapy (30-60 Gy) was administered to 30 patients: 10 after gross total resection or simple cholecystectomy, 10 after subtotal resection or surgical biopsy, and 10 after percutaneous decompression. Overall survival was 26% at 3 years and 15% at 5 years. The 5-year survival rate was 15% for 17 patients treated by surgery alone and 14% for 30 patients treated with radiotherapy alone or following surgery. After gross total resection, median survival time was 26.1 months for 9 patients treated by surgery alone vs. 43.4 months for 8 patients who received postoperative radiotherapy. After gross total resection or cholecystectomy, 5-year survival rates were 19% for surgery alone and 35% for surgery and postoperative radiotherapy (P=.07). Median survival for 10 patients treated by radiation therapy alone after percutaneous decompression was 6.4 months. Postoperative adjuvant radiotherapy was well tolerated and may improve local-regional control after gross total resection.

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.

Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors

OBJECTIVE

The objective of this article is to introduce a simple method for classifying cholangiocarcinomas and to apply this system to analyze a large number of patients from a single institution.

SUMMARY BACKGROUND DATA

For the past 2 decades, most western reports on cholangiocarcinoma have separated intrahepatic from extrahepatic tumors and have subclassified this latter group into proximal, middle, and distal subgroups. However, "middle" lesions are uncommon and are managed most often either with hilar resection or with pancreatoduodenectomy. The spectrum of cholangiocarcinoma, therefore, is best classified into three broad groups: 1) intrahepatic, 2) perihilar, and 3) distal tumors. These categories correlate with anatomic distribution and imply preferred treatment.

METHODS

The records of all patients with histologically confirmed cholangiocarcinoma who underwent surgical exploration at The Johns Hopkins Hospital over a 23-year period were reviewed.

RESULTS

Of 294 patients with cholangiocarcinoma, 18 (6%) had intrahepatic, 196 (67%) had perihilar, and 80 (27%) had distal tumors. Age, gender, race, and associated diseases were similar among the three groups. Patients with intrahepatic tumors, by definition, were less likely (p < 0.01) to be jaundiced and more likely (p < 0.05) to present with abdominal pain. The resectability rate increased with a more distal location (50% vs. 56% vs. 91%), and resection improved survival at each site. Five-year survival rates for resected intrahepatic, perihilar, and distal tumors were 44%, 11%, and 28%, and median survival rates were 26, 19, and 22 months, respectively. Postoperative radiation therapy did not improve survival. In a multivariate analysis resection (p < 0.001. hazard ratio 2.80), negative microscopic margins (p < 0.01, hazard ratio 1.79), preoperative serum albumin (p < 0.04, hazard ratio 0.82), and postoperative sepsis (p < 0.001, hard ratio 0.27) were the best predictors of outcome.

CONCLUSIONS

Cholangiocarcinoma is best classified into three broad categories. Resection remains the primary treatment, whereas postoperative adjuvant radiation has no influence on survival. Therefore, new agents or strategies to deliver adjuvant therapy are needed to improve survival.