1
|
Boškoski I, Tringali A, Familiari P, Bove V, Landi R, Attili F, Perri V, Onder G, Mutignani M, Costamagna G. A 17 years retrospective study on multiple metal stents for complex malignant hilar biliary strictures: Survival, stents patency and outcomes of re-interventions for occluded metal stents. Dig Liver Dis 2019; 51:1287-1293. [PMID: 31036471 DOI: 10.1016/j.dld.2019.03.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/01/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic placement of SEMSs for malignant hilar biliary strictures (MHBS) is well-established palliative treatment for inoperable patients. Objectives of this study were evaluation of survival and stents patency after placement of multiple SEMS for palliation of complex MHBS. METHODS Retrospective review of patients with MHBS that underwent ERCP with insertion of multiple SEMSs for palliation. Survival-associated factors and stents patency were analyzed by Cox multivariate analysis. RESULTS Between January 1998 and January 2015, 740 patients with nonoperable MHBS that underwent ERCP were identified and only 18.2% of these received multiple SEMSs. Complications were observed in 7.5% of the patients with no procedure-related mortality. Palliative therapies (chemotherapy, external beam radiotherapy and high dose rate brachytherapy) were done in some patients, and outcomes were evaluated. Overall mean survival of the 134 patients was 323 days. Of these, 59% did not had stents malfunction while 41% patients had episodes of SEMSs malfunction and mean survival after re-interventions was 502.9 days. Survival was not influenced by type of tumor, sex or age. CONCLUSIONS Endoscopic multiple SEMSs placement is safe and effective in patients with complex MHBS. Survival is independent from the type and complexity of MHBS while is prolonged in patients undergoing HDR brachytherapy. Prompt recognition of SEMSs malfunction is fundamental for survival.
Collapse
Affiliation(s)
- Ivo Boškoski
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy.
| | - Andrea Tringali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Pietro Familiari
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Vincenzo Bove
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Rosario Landi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Fabia Attili
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Vincenzo Perri
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| | - Graziano Onder
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy
| | | | - Guido Costamagna
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy; Catholic University, Centre for Endoscopic Research therapeutics and Training (CERTT), Rome, Italy
| |
Collapse
|
2
|
Kariya CM, Wach MM, Ruff SM, Ayabe RI, Lo WM, Torres MB, Petrick JL, McNeel TS, Davis JL, McGlynn KA, Hernandez JM. Postbiliary drainage rates of cholangitis are impacted by procedural technique for patients with supra-ampullary cholangiocarcinoma: A SEER-Medicare analysis. J Surg Oncol 2019; 120:249-255. [PMID: 31044430 DOI: 10.1002/jso.25485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/10/2019] [Accepted: 04/14/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal approach to biliary drainage for patients with supra-ampullary cholangiocarcinoma remains undetermined. Violation of sphincter of Oddi results in bacterial colonization of bile ducts and may increase postdrainage infectious complications. We sought to determine if rates of cholangitis are affected by the type of drainage procedure. METHODS We examined the Surveillance, Epidemiology, and End Results-Medicare linked database from 1991 to 2013 for cholangiocarcinoma. Biliary drainage procedures were categorized as sphincter of Oddi violating (SOV) or sphincter of Oddi preserving (SOP). Patients were stratified by resection. RESULTS A total of 1914 patients were included in the final analysis. A total of 1264 patients did not undergo a postdrainage resection (SOP 83, SOV 1181) while 650 did undergo a postdrainage resection (SOP 26, SOV 624). For those patients not undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was 19% compared with 34% in the SOV cohort (P = 0.007). For those patients undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was less than 42.3% compared with 30% in the SOV cohort (P = 0.66). CONCLUSION For patients with supra-ampullary cholangiocarcinoma that did not undergo resection, biliary drainage procedures that violated the sphincter of Oddi were associated with increased rates of cholangitis.
Collapse
Affiliation(s)
- Christine M Kariya
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Michael M Wach
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Samantha M Ruff
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Reed I Ayabe
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Winifred M Lo
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Madeline B Torres
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Jessica L Petrick
- Metabolic Epidemiology Branch, National Cancer Institute, Rockville, Maryland
| | | | - Jeremy L Davis
- Surgical Oncology Program, National Cancer Institute, Bethesda, Maryland
| | - Katherine A McGlynn
- Metabolic Epidemiology Branch, National Cancer Institute, Rockville, Maryland
| | | |
Collapse
|
3
|
Buettner S, Wilson A, Margonis GA, Gani F, Ethun CG, Poultsides GA, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Pawlik TM. Assessing Trends in Palliative Surgery for Extrahepatic Biliary Malignancies: A 15-Year Multicenter Study. J Gastrointest Surg 2016; 20:1444-52. [PMID: 27121233 PMCID: PMC5450034 DOI: 10.1007/s11605-016-3155-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/18/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Extrahepatic biliary malignancies are often diagnosed at an advanced stage. We compared patients with unresectable perihilar cholangiocarcinoma (PHCC) and gallbladder cancer (GBC) who underwent a palliative procedure versus an aborted laparotomy. METHODS Seven hundred seventy-seven patients who underwent surgery for PHCC or GBC between 2000 and 2014 were identified. Uni- and multivariable analyses were performed to identify factors associated with outcome. RESULTS Utilization of preoperative imaging increased over time (CT use, 80.1 % pre-2009 vs. 90 % post-2009) (p < 0.001). The proportion of the patients undergoing curative-intent resection also increased (2000-2004, 67.0 % vs. 2005-2009, 74.5 % vs. 2010-2014, 78.8 %; p = 0.001). The planned surgery was aborted in 106 (13.7 %) patients and 94 (12.1 %) had a palliative procedure. A higher incidence of postoperative complications (19.2 vs. 3.8 %, p = 0.001) including deep surgical site infections (8.3 vs. 1.1 %), bleeding (4.8 vs. 0 %), bile leak (6.0 vs. 0 %) and longer length of stay (7 vs. 4.5 days) were observed among the patients who underwent a palliative surgical procedure versus an aborted non-therapeutic, non-palliative laparotomy (all p < 0.05). OS was comparable among the patients who underwent a palliative procedure (8.7 months) versus an aborted laparotomy (7.8 months) (p = 0.23). CONCLUSION Increased use of advanced imaging modalities was accompanied by increased curative-intent surgery. Compared with patients in whom surgery was aborted, patients who underwent surgical palliation demonstrated an increased incidence of postoperative morbidity with comparable survival.
Collapse
Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Ana Wilson
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Georgios Antonis Margonis
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Cecilia G. Ethun
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| |
Collapse
|
4
|
Soares KC, Kamel I, Cosgrove DP, Herman JM, Pawlik TM. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobiliary Surg Nutr 2014; 3:18-34. [PMID: 24696835 DOI: 10.3978/j.issn.2304-3881.2014.02.05] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 12/16/2022]
Abstract
Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6(th) decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease.
Collapse
Affiliation(s)
- Kevin C Soares
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab Kamel
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David P Cosgrove
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
5
|
Gomez D, Patel P, Lacasia-Purroy C, Byrne C, Sturgess R, Palmer D, Fenwick S, Poston G, Malik H. Impact of specialized multi-disciplinary approach and an integrated pathway on outcomes in hilar cholangiocarcinoma. Eur J Surg Oncol 2014; 40:77-84. [DOI: 10.1016/j.ejso.2013.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 09/21/2013] [Accepted: 10/13/2013] [Indexed: 02/07/2023] Open
|
6
|
Tan LBK, Madhavan K, Chang SKY. Intrahepatic segment V biliary enteric bypass. ANZ J Surg 2013; 84:885-6. [PMID: 24171909 DOI: 10.1111/ans.12329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Liza B K Tan
- Department of General Surgery, National University Hospital of Singapore, Singapore
| | | | | |
Collapse
|
7
|
Mishreki AP, Lim E, Cranefield P, Pascoe S, Jackson S, Stell DA. Low rate of active treatment of patients with hilar cholangiocarcinoma. Ann R Coll Surg Engl 2013; 95:349-52. [PMID: 23838498 DOI: 10.1308/003588413x13629960046598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The results of surgical resection and palliative chemotherapy use in hilar cholangiocarcinoma (HC) have been well publicised but the proportion of patients able to undergo these treatments and the comparative outcomes in a population of patients with HC are less well known. METHODS Patients with HC were identified by review of all patients undergoing percutaneous cholangiography over a nine-year period (2002-2010) in a tertiary facility. The treatment undertaken and outcomes were recorded. RESULTS Overall, 68 patients were identified (37 female) with a median age of 70 years. Forty-five (66%) were treated solely by insertion of a metal stent (median survival 4.73 months) and nine (13%) also received palliative chemotherapy (median survival 13.7 months). Persisting jaundice after stent insertion was noted in 18 of 35 patients (51%) tested within one month of death. Fourteen patients (21%) underwent surgical resection (median survival 20.2 months). CONCLUSIONS Patients undergoing surgical resection had significantly longer survival than those receiving only a palliative stent but not compared with those also receiving palliative chemotherapy, with short-term follow-up. Only a third of patients, however, receive active treatment (surgery or chemotherapy) and improvements in long-term biliary palliation are needed.
Collapse
|
8
|
Abstract
BACKGROUND Radical resection remains the only curative treatment for hilar cholangiocarcinoma (HCCA). Only a limited proportion of patients, however, are eligible for resection. The survival and prognostic factors of these patients are largely unknown. The aim of this study was to evaluate survival and prognostic factors in unresectable patients presenting with HCCA. METHODS We performed a cohort study of the denominator of HCCA patients seen in a tertiary referral center between March 2003 and March 2009. Demographics, treatment, pathology results, and survival were analyzed. RESULTS A total of 217 patients with suspected HCCA were identified. Ninety-five patients (40 %) underwent laparotomy, and in 57 (63 %) of these patients resection was performed. Overall median and 5-year survival of resected patients were 37 months and 43 %, respectively, as compared to 13 months and 7 % in unresectable patients. In unresectable patients, median survival was better in patients with locally advanced disease (16 months) as compared to patients with hepatic and extrahepatic metastases (5 and 3 months, p < 0.001). Of the 160 unresectable patients, 17 (10 %) survived longer than 3 years. CONCLUSION Of the patients presenting with HCCA in our center, 26 % proved resectable. The 7 % long-term survival rate of unresectable patients is remarkable and emphasizes the indolent growth of some of these tumors. Patients with metastases had a much worse prognosis with a median of 4 months.
Collapse
|
9
|
Li HY, Zhou SJ, Li M, Xiong D, Singh A, Guo QX, Liu CA, Gong JP. Diagnosis and cure experience of hepatolithiasis-associated intrahepatic cholangiocarcinoma in 66 patients. Asian Pac J Cancer Prev 2012; 13:725-9. [PMID: 22524851 DOI: 10.7314/apjcp.2012.13.2.725] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The management of hepatolithiasis combined with intrahepatic cholangicarcinoma (IHHCC) remains a challenge due to poor prognosis. The aim of this study was to summarize our diagnosis and cure experience of IHHCC over the recent 10 years. METHODS From January 1996 to January 2006, 66 patients with IHHCC were reviewed retrospectively. RESULTS Of the 66 patients, 52 underwent surgical resection (radical resection in 38 and palliative in 14) and 8 patients abdominal exploration, while the other 6 cases received endoscopic retrograde biliary internal drainage and stent implantation. In this series, correct diagnosis of advanced stage was made during operation in 8 cases (8/60, 13.3%) and all of them (underwent unnecessary abdominal exploration, among them the positive rate of CA19-9 was 100%, and the positive rate of CEA was 87.6% (7/8), incidence rate of ascites was 100% and short-term significant weight loss was 100%, with median overall survival of only 4 months. CONCLUSION Radical resection is mandatory for IHHCC patient to achieve long-term survival, the CT and MR imaging features of IHHCC being concentric enhancement. Patients with IHHCC have significant higher CA199 and significant higher CEA and short-term significant weight loss and ascites should be considered with advanced stage of IHHCC and unnecessary non-therapeutic laparotomies should be avoided.
Collapse
Affiliation(s)
- Hong-Yang Li
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital, Chongqing University of Medical Sciences, Chongqing, China
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Matull WR, Dhar DK, Ayaru L, Sandanayake NS, Chapman MH, Dias A, Bridgewater J, Webster GJM, Bong JJ, Davidson BR, Pereira SP. R0 but not R1/R2 resection is associated with better survival than palliative photodynamic therapy in biliary tract cancer. Liver Int 2011; 31:99-107. [PMID: 20846273 PMCID: PMC2997861 DOI: 10.1111/j.1478-3231.2010.02345.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is a need for better management strategies to improve the survival and quality of life in patients with biliary tract cancer (BTC). AIM To assess prognostic factors for survival in a large, non-selective cohort of patients with BTC. METHOD We compared outcomes in 321 patients with a final diagnosis of BTC (cholangiocarcinoma n = 237, gallbladder cancer n = 84) seen in a tertiary referral cancer centre between 1998 and 2007. Survival according to disease stage and treatment category was compared using log-rank testing. Cox's regression analysis was used to determine independent prognostic factors. RESULTS Eighty-nine (28%) patients underwent a surgical intervention with curative intent, of whom 38% had R0 resections. Among the 321 patients, 34% were given chemo- and/or radiotherapy, 14% were palliated with photodynamic therapy (PDT) and 37% with biliary drainage procedures alone. The overall median survival was 9 months (3-year survival, 14%). R0-resective surgery conferred the most favourable outcome (3-year survival, 57%). Although patients palliated with PDT had more advanced clinical T-stages, their survival was similar to those treated with attempted curative surgery but who had positive resection margins. On multivariable analysis, treatment modality, serum carbohydrate-associated antigen 19-9, distant metastases and vascular involvement were independent prognostic indicators of survival. CONCLUSION In this large UK series of BTC, palliative PDT resulted in survival similar to those with curatively intended R1/R2 resections. Surgery conferred a survival advantage only in patients with R0 resection margins, emphasising the need for accurate pre-operative staging.
Collapse
Affiliation(s)
- WR Matull
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London
| | - DK Dhar
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London
| | - L Ayaru
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London, Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| | - NS Sandanayake
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London, Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| | - MH Chapman
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London, Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| | - A Dias
- Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| | - J Bridgewater
- UCL Cancer Institute, UCL Faculty of Biomedical Sciences, University College London
| | - GJM Webster
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London, Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| | - JJ Bong
- University Department of Surgery, Royal Free Hampstead NHS Trust and Royal Free and University College Medical School, London, U.K
| | - BR Davidson
- University Department of Surgery, Royal Free Hampstead NHS Trust and Royal Free and University College Medical School, London, U.K
| | - SP Pereira
- Institute of Hepatology, UCL Faculty of Biomedical Sciences, University College London, Department of Gastroenterology, UCL Hospitals NHS Foundation Trust
| |
Collapse
|
11
|
Bi AH, Zeng ZC, Ji Y, Zeng HY, Xu C, Tang ZY, Fan J, Zhou J, Zeng MS, Tan YS. Impact factors for microinvasion in intrahepatic cholangiocarcinoma: a possible system for defining clinical target volume. Int J Radiat Oncol Biol Phys 2010; 78:1427-36. [PMID: 20378269 DOI: 10.1016/j.ijrobp.2009.09.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 09/27/2009] [Accepted: 09/28/2009] [Indexed: 12/20/2022]
Abstract
PURPOSE To quantify microscopic invasion of intrahepatic cholangiocarcinoma (IHC) into nontumor tissue and define the gross tumor volume (GTV)-to-clinical target volume (CTV) expansion necessary for radiotherapy. METHODS AND MATERIALS One-hundred IHC patients undergoing radical resection from January 2004 to July 2008 were enrolled in this study. Pathologic and clinical data including maximum tumor diameter, tumor boundary type, TNM stage, histologic grade, tumor markers, and liver enzymes were reviewed. The distance of microinvasion from the tumor boundary was measured by microscopy. The contraction coefficient for tumor measurements in radiographs and slide-mounted tissue was calculated. SPSS15.0 was used for statistical analysis. RESULTS Sixty-five patients (65%) exhibited tumor microinvasions. Microinvasions ranged from 0.4-8 mm, with 96% of patients having a microinvasion distance ≤6 mm measured on slide. The radiograph-to-slide contraction coefficient was 82.1%. The degree of microinvasion was correlated with tumor boundary type, TNM stage, histologic grade, and serum levels of carbohydrate antigen 19-9, alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase and alkaline phosphatase. To define CTV accurately, we devised a scoring system based on combination of these factors. According to this system, a score ≤1.5 is associated with 96.1% sensitivity in detecting patients with a microextension ≤4.9 mm in radiographs, whereas a score ≥2 has a 95.1% sensitivity in detecting microextension ≤7.9 mm measured on radiograph. CONCLUSIONS Patients with a score ≤1.5 and ≥2 require a radiographic GTV-to-CTV expansions of 4.9 and 7.9 mm, respectively, to encompass >95% of microinvasions.
Collapse
Affiliation(s)
- Ai-Hong Bi
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Park J, Kim MH, Kim KP, Park DH, Moon SH, Song TJ, Eum J, Lee SS, Seo DW, Lee SK. Natural History and Prognostic Factors of Advanced Cholangiocarcinoma without Surgery, Chemotherapy, or Radiotherapy: A Large-Scale Observational Study. Gut Liver 2009; 3:298-305. [PMID: 20431764 PMCID: PMC2852727 DOI: 10.5009/gnl.2009.3.4.298] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 09/04/2009] [Indexed: 12/11/2022] Open
Abstract
Background/Aims We aimed to evaluate survival time and prognostic factors in patients with advanced unresectable cholangiocarcinoma who have not received surgery, chemotherapy, or radiotherapy. Methods A total of 1,377 patients, who were diagnosed with primary cholangiocarcinoma between 1996 and 2002, were reviewed retrospectively according to the following inclusion criteria: histologically proven primary adenocarcinoma arising from the bile-duct epithelium, advanced unresectable stages, no severe comorbidity that can affect survival time, and no history of surgery, chemotherapy, or radiotherapy. Results Of the 1,377 cases reviewed, 330 patients complied with the inclusion criteria and were thus eligible to participate in this study; 203 had intrahepatic cholangiocarcinoma and 127 had hilar cholangiocarcinoma. The overall survival time of the entire cohort (n=330) was median 3.9 months (range; 0.2 to 67.1). The survival time was significantly shorter in the intrahepatic cholangiocarcinoma group (3.0±5.3 months) than in the hilar cholangiocarcinoma group (5.9±10.1 months; Kaplan-Meier survival analysis). Multivariate analysis revealed that distant metastasis was a poor prognostic factor for intrahepatic cholangiocarcinoma (p< 0.001), baseline serum albumin >3.0 g/dL was a favorable prognostic factor (p=0.02), and baseline serum carcinoembryonic antigen level >30 ng/mL was a poor prognostic factor for hilar cholangiocarcinoma (p=0.01). Conclusions The median survival of advanced unresectable cholangiocarcinoma is dismal.
Collapse
Affiliation(s)
- Jongha Park
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Kozarek RA. Inflammation and carcinogenesis of the biliary tract: update on endoscopic treatment. Clin Gastroenterol Hepatol 2009; 7:S89-94. [PMID: 19896106 DOI: 10.1016/j.cgh.2009.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 08/20/2009] [Accepted: 08/20/2009] [Indexed: 12/21/2022]
Abstract
Both diagnosis and treatment of cholangiocarcinoma are suboptimal. From the former standpoint, fluorescence in situ hybridization, direct cholangioscopy, endocystoscopy, and optical coherence tomography are just a few of the myriad technologies being studied or employed to improve diagnostic yield. From the latter standpoint, most series suggest that fewer than 1 third of patients are resectable for cure, although liver transplantation has increasingly been used in a subset of cholangiocarcinoma patients with extrahepatic disease. Palliation has included chemotherapy which is of dubious value in most series. Instead, a majority of therapies have addressed mechanisms to improve biliary drainage to delay and preclude hepatic failure and minimize the risk of cholangitis. Although the latter has been accomplished with surgery and attempted with external beam irradiation and brachytherapy, percutaneous and/or endoscopic drainage are the most commonly employed methods in widespread use. There are prospective, randomized studies that suggest that bilateral stenting is associated with improved outcomes in bifurcation lesions if plastic stents are placed, that percutaneous transhepatic biliary drainage is more successful than endoscopic stenting in Klatskin tumors, that self-expandable biliary stents have prolonged patency compared with plastic prostheses, and that, if approached with computed tomography and magnetic resonance imaging guidance to preclude contamination of the contralateral undrained system, outcomes are comparable in patients treated with unilateral as opposed to bilateral self-expandable metal stents. There is a single prospective, randomized study suggesting that patients treated with endoscopic or percutaneous stenting in conjunction with photodynamic therapy have prolonged survival compared with stent placement alone.
Collapse
Affiliation(s)
- Richard A Kozarek
- Digestive Disease Institute at Virginia Mason, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
| |
Collapse
|
14
|
Abstract
Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.
Collapse
|
15
|
Paik WH, Park YS, Hwang JH, Lee SH, Yoon CJ, Kang SG, Lee JK, Ryu JK, Kim YT, Yoon YB. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc 2009; 69:55-62. [PMID: 18657806 DOI: 10.1016/j.gie.2008.04.005] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Accepted: 04/12/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Endoscopic or percutaneous biliary drainage with self-expandable metallic stents (SEMS) is widely used for the palliation of cholestasis in patients with advanced hilar cholangiocarcinoma. However, little is known about which is the better option in patients with advanced hilar cholangiocarcinoma. We compared the clinical outcomes of these 2 methods of biliary decompression in these patients. DESIGN AND SETTING Multicenter retrospective study. PATIENTS A total of 85 patients with newly diagnosed advanced hilar cholangiocarcinoma (Bismuth III or Bismuth IV) and who did not receive an operation, chemotherapy, or radiotherapy were retrospectively reviewed. Forty-four of the 85 received endoscopic SEMS and 41 received percutaneous SEMS. INTERVENTIONS Endoscopic SEMS or percutaneous SEMS. MAIN OUTCOME MEASUREMENTS AND RESULTS Baseline characteristics were similar in the 2 groups, but the rate of successful biliary decompression was significantly higher in the percutaneous SEMS group than in the endoscopic SEMS group (92.7% vs 77.3%, respectively, P= .049). Overall rates of procedure-related complications were similar for the 2 groups, but 1 death (from biliary sepsis) occurred in the endoscopic SEMS group. Median survival of patients in whom biliary drainage was successful initially, regardless of which procedure was performed, was much longer than that of patients who had failed biliary drainage (8.7 months vs 1.8 months, respectively, P< .001). Once successful biliary decompression had been achieved, median survival and stent patency duration were similar in the 2 study groups. LIMITATION Retrospective study. CONCLUSIONS Percutaneous SEMS may be chosen for initial biliary drainage in patients with advanced type III or IV hilar cholangiocarcinoma, given higher initial success rate and low level of procedure-related cholangitis.
Collapse
Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|